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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/tuberculosisprevOOknop 


TUBERCULOSIS 

A  PREVENTABLE  AND  CURABLE  DISEASE 


IMPORTANT    RECENT    BOOKS    AND     MONOClRAPHS 
KV  THE   SAME  AUTHOR: 


"  Les  Sanatoria."  These  pour  le  Doctorat  en  Medecine.  Pre- 
sentee et  soutenue  devant  la  Faculte  de  Medecine  de  Paris. 

Paris,  1S95 

"  Les  Sanatoria,  Traitement  et  Prophylaxie  de  la  Phtisie  Pulnio- 
naire."  Paris,  igoo 

"  Pulmonary  Tuberculosis,  Its  Modern  Prophylaxis  and  the  Treat- 
ment in  Special  Institutions  and  at  Home."  Alvarenga  Prize 
Essay.  Philadelphia,  iSt/j 

"Die  Tuberkulose  als  Volkskrankheit  und  deren  P>ekampfung." 
Kongress  Preisschrift.  Berlin,  1900 

"  Tuberculosis  as  a  Disease  of  the  Masses  and  How  to  Combat  It." 
Six  editions  from  1900  to  iqog.  New  York 

Translations  of  this  have  appeared  as  Arabic,  Brazilian,  Bulga- 
rian, Chinese,  Dutch,  English,  Finnish,  French,  Hebrew, 
Hungarian,  Icelandic,  Italian,  Japanese,  Mexican,  Norwe- 
gian, Polish,  Russian,  Serbian,  Siberian,  Spanish,  Swedish, 
and  Turkish  editions  between  1900  and  u/x). 

"Tuberculosis"  in  Twentieth  Century  Practice  of  Medicine. 

New  York,  1900 

"A  Few  Thoughts  on  the  Medical  and  Social  Aspect  of  Tubercu- 
losis at  the  P>eginning  of  the  Twentieth  Century."  Contribu- 
tion to  Prof,  von  Leyden's  Festschrift.  Berlin,  1902 

"  Woman's  Duty  Towards  the  Health  of  the  Nation." 

Bostf»n,  1904 

"  Medicine  and  Eaw  in  Relation  to  the  Alcohol,  Venereal  Disease 
and  Tuberculosis  Problems."  New  York,  1906 

"  A  Plea  for  Cremation."  Chicago,  1907 

"Tuberculosis"  in  Nelson's  Encyclopedia.  New  York,  1907 

"  The  Etiology,  Prophylaxis  and  Treatment  of  the  Social  111." 

New  York,  1908 

"  A  Plea  for  More  Sanatoria  for  the  ConsumiHive  Poor  in  all  Stages 
of  the  Disease."  New  York,  k/jS 

'•  Sun,  Air,  and  Water,  Their  Use  in  the  Preservation  of  Health  and 
the  Cure  of  Disease."  Wa.shington,  k/jS 

"Public  Measures  in  the  Propliylaxis  of  Tuberculosis."  Contri- 
bution to  tlie  American  Treatise  on  Tul)crculosis. 

New  York,   n;ocj 

"  Tlie  Hfjpeful  Outlook  of  the  Tuberculosis  I'roblem  in  the  United 
States.  ^t.  Louis,  i</>9 


Professor  Robert  Koch,  Discoverer  of  the  Tubercle  Bacillus. 


TUBERCULOSIS 

A    PREVENTABLE    AND 
CURABLE   DISEASE 

MODERN  METHODS  FOR  THE  SOLUTION 
■      OF  THE  TUBERCULOSIS  PROBLEM 


BY 
S.   ADOLPHUS   KNOPF,   M.D.    (New  York  and  Paris) 

Professor  of  Medicine,  Department  of  Phthisiotherapy,  at  the  New  York  Post- 

Graduate  Medical  school  and  Hospital;  Senior  Attending  Physician 

to  the  Riverside  Hospital  —  Sanatorium  for  Consumptives 

of  the  City  of  New  York,  etc. 


NEW  EDITION 


NEW   YORK 

MOFFAT,  YARD  AND   COMPANY 

1916 


a-, 


Copyright   1909,  by 
MOFFAT,   YARD  AND  COMPANY 

New  York 

All  Rights  Reserved 

PUBLISHED,   JUNE,     igCK) 


1-'  !  I 

K 1  5  X  \ 


Sto  my  MASTERS  in  MEDICINE  in  Amer- 
ica, France,  and  Germany,  by  whose  wisdom  I  am 
guided,  by  whose  experience  I  gain  courage  for  7ny 
work,  and  whose  lives  are  my  constant  inspiration. 

®:0  the  NOBLE  MEN  and  WOMEN  inside 
and  outside  oj  the  medical  profession  all  over  the 
civilized  world,  whose  unselfish  labors  have  been  so 
helpftd  to  the  anti-tuber cido sis  cause. 

Eo  the  STATESMEN  and  PHILANTHRO- 
PISTS to  whose  wisdom  and  generosity  we  look  for 
help  in  the  realization  oj  our  utmost  desires,  the 
eradication  of  the  Great  White  Plague. 


MOTTO 


To  combat  tuberculosis  successfully,  requires  the 
combined  action  of  a  wise  government,  well-trained 
physicians,  and  an  intelligent  people. 


PREFACE  TO   SECOND  EDITION 

The  first  edition  of  this  volume  was  more  than 
kindly  received  by  the  medical  profession  and  the 
general  public.  For  the  words  of  praise  which  were 
bestowed  upon  it  in  numerous  reviews  and  personal 
letters  I  feel  deeply  grateful.  The  criticisms  were 
few,  but  for  them  also  I  wish  to  express  my  sincerest 
thanks.  Some  referred  to  scientific  points  about 
which  none  of  us  as  yet  are  certain,  others  referred 
to  more  or  less  serious  typographical  errors  which 
have  now  been  corrected,  and  a  few  new  phases  in 
the  popular  campaign  have  been  described. 

To  one  assertion,  however,  which  appeared  in 
two  or  three  of  the  criticisms  I  must  reply  in 
detail,  and  leave  the  public  to  judge  the  right  of 
the  case.  It  has  been  said  that  a  number  of  my 
statements  regarding  the  prevention  and  cure  of 
tuberculosis,  in  its  social  as  well  as  in  its  medical 
aspect,  were  non-authoritative,  and  not  based  on 
experience.  My  reply  to  this  serious  criticism  is 
merely  to  enumerate  the  opportunities  which  I 
have  had  in  the  space  of  twenty-five  years,  for  the 
study  and  observation  of  this  disease. 

ix 


X  PREFACE  TO  SECOND  EDITION 

I  began  my  medical  career  as  a  student  at  the 
^ledical  College  of  the  University  of  Southern 
California,  in  the  early  'eighties.  My  first  impor- 
tant position  was  that  of  interne  in  the  Los  Angeles 
County  Hospital,  where  the  majority  of  patients 
consisted  of  consumptives,  nearly  all  of  them  in 
the  more  advanced  stages.  They  had  come 
thither  thinking  that  the  glorious  chmate  alone 
would  suffice  to  cure  them.  Some  had  come  with 
little  or  no  money,  others  had  spent  their  all  and 
had  not  enough  left  to  return  to  their  Eastern 
homes  which,  perhaps,  all  of  them  had  left  in  the 
hope  that  a  few  weeks  in  Southern  California 
would  restore  them  to  health  and  vigor  when  they 
would  find  work  and  be  able  to  support  them- 
selves. This  delusion  filled  the  Los  Angeles 
County  Hospital,  year  in  and  year  out,  with  hun- 
dreds of  poor,  discouraged  consumptives,  many 
of  them  hopelessly  ill.  They  became  a  burden 
to  a  strange  community.  It  was  this  situation 
which  inspired  me  to  devote  my  life  to  the  anti- 
tuberculosis cause,  to  seek  out  and  to  study  the 
means  of  curing  tuberculosis  as  far  as  it  was 
practicable  without  regard  to  climate,  and  to  labor 
for  the  early  recognition  of  the  disease. 

I  came  to  New  York  to  finish  my  studies  in 
the  celebrated  Bellevue  Hospital  Medical  College, 
where  I  also  took  my  degree.    In  those  days  con- 


PREFACE  TO  SECOND  EDITION  xi 

sumptives  were  treated  in  general  hospitals.  It 
was  nothing  unusual  for  a  consumptive  to  have 
some  one  afflicted  with  malaria,  pneumonia,  or 
heart  disease  as  a  neighbor  in  the  ward.  Under 
these  conditions  consumption  was  propagated 
among  other  patients,  nor  was  the  infection  con- 
fined to  the  patients  alone.  I  sadly  remember 
that  not  a  few  of  my  colleagues,  serving  in  the 
hospitals,  fell  victims  to  the  disease. 

Subsequent  to  my  graduation  at  Bellevue  I 
engaged  in  general  practice  in  the  tenement  house 
districts  of  New  York.  Here  I  learned  much  of 
the  social  causes  of  tuberculosis,  of  the  tenement 
house  problem,  alcohoHsm,  sweatshops,  and  child 
labor, — all  predisposing  factors  to  tuberculosis. 
Feeling  that  I  had  much  more  to  learn  regarding 
tuberculosis  science,  I  went  abroad  and  devoted 
six  years  to  additional  study.  I  remained  several 
years  in  Paris,  matriculated  as  a  regular  medical 
student,  and  served  as  assistant  in  the  general  and 
special  hospitals,  which  enabled  me  to  take  the 
degree  of  Doctor  of  Medicine  of  that  great  fac- 
ulty. Prior  to  presenting  my  thesis  for  this  de- 
gree, I  visited  all  the  leading  European  and 
American  sanatoria  and  health  resorts  conse- 
crated to  the  treatment  of  tuberculosis.  My 
French  doctor  thesis  had  for  its  title  "Les  Sana- 
toria,  Traitement   et   Prophylaxie   de   la   Phtisie 


xii  PREFACE  TO  SECOND  EDITION 

Pulmonaire."  Because  of  the  above  mentioned 
criticisms  I  may  be  permitted  to  mention  that  this 
thesis  received  the  highest  mark  (extremement 
satisfait)  from  the  jury  which  presided  over  its 
defense,  and  the  French  Academy  of  Medicine 
and  the  Institute  of  France  made  the  author  of  it 
a  laureate.  The  enlarged  English  translation  of 
this  thesis  was  awarded  with  the  Alvarenga  prize  by 
the  College  of  Physicians  of  Philadelphia  in  1898. 

My  practical  training  as  a  sanatorium  physician 
I  received  after  my  graduation  in  Paris,  by  a 
lengthy  sojourn  in  the  Falkenstein  Sanatorium 
as  assistant  to  that  great  and  immortal  teacher 
of  modern  phthisio-therapy,  Geheimrath  Professor 
Dettweiler,  then  Director  of  that  institution. 

The  two  above  mentioned  volumes  which  passed 
several  editions  were  purely  scientific  treatises, 
but  it  was  also  the  author's  good  fortune  to  receive 
recognition  for  his  popular  essay  entitled  ''Tuber- 
culosis as  a  Disease  of  the  Masses  and  How  to 
Combat  it."  The  Tuberculosis  Congress  which 
convened  in  Berlin  in  1899  bestowed  upon  this 
work  the  International  Congress  prize  of  4000 
Marks  ($1000).  This  little  essay  has  since  been 
translated  into  25  different  languages  and  largely 
distributed  throughout  the  civilized  world. 

Since  my  return  to  the  United  States  in  1896,  I 
have  had  no  lack  of  opportunities  to  study  tuber- 


IPREFACE  TO  SECOND   EDITION  xiii 

culosis  in  its  sociological  as  well  as  in  its  medical 
aspect.  It  is  my  privilege  to  have  been  one  of  the 
founders  of  the  New  York  Tuberculosis  Committee, 
and  of  our  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis.  The  admirable  work 
of  these  organizations,  as  far  as  the  social  combat 
of  tuberculosis  is  concerned,  is  too  wtII  known  to 
need  mentioning  here.  Through  the  many  years 
of  my  connection  with  the  New  York  Health 
Department  as  Associate  Director  of  its  clinics 
for  pulmonary  diseases  and  as  senior  attending 
physician  of  the  Riverside  Hospital-Sanatorium 
for  the  consumptive  poor  of  this  city,  I  believe 
that  my  opportunities  for  observing  and  learning 
have  been  and  are  still  exceptional.  It  is  on  the 
basis  of  these  many  years  of  experience  that  I 
have  laid  down  in  this  volume  what  I  consider 
not  only  my  thoughts  but  those  of  the  best  among 
our  leading  tuberculosis  specialists. 

In  conclusion  I  should  like  to  reproduce  a  few 
of  the  opinions  that  have  been  expressed  by  leading 
men  on  the  appearance  of  the  first  edition  of  this 
volume : 

His   Excellency,   Real   Privy    Councillor,    Pro 
FESSOR  Robert  Koch,  of  Berlin. 
"Such  work  as  yours  should  be  welcomed,  as  it  is 
destined  to  play  an  important  part  in  the  enlightenment 
of  the  people  and  the  American  people  seem  to  me 


xiv  PREFACE  TO  SECOND  EDITION 

particularly    susceptible    to    such    education.      Your 
book  is  sure  to  meet  with  great  success." 

William  Osler,  M.  D.,  LL.  D.,  Regius  Professor  of 
Medicine,  Oxford  University,  England. 
"I  am  greatly  pleased  with  your  new  book.  It  is 
admirable  in  every  way — form  and  substance  are 
equally  good.  I  am  sure  it  must  be  having  a  great 
success." 

Mr.  Ernest  P.  Bicknell,  Director  of  the  American 
National  Red  Cross,  Washington,  D.  C;  Formerly 
Superintendent  Chicago  Bureau  of  Charities. 
"I  have  been  testing  the  value  of  this  book  by  sub- 
mitting to  it  many  of  the  questions  and  problems  which 
have    been  encountered  in  a  somewhat  extended  and 
varied  relationship  with  persons  afflicted  by  tuberculosis 
in  tenements,  hovels,  schools,  shops,  and  public  institu- 
tions.   And  in  every  instance  I  have  found  the  answer 
concise,  definite,  positive." 

Hermann  M.   Biggs,  M.   D.,  LL.   D.,   Professor  of 
Medicine,    New    York    University    and    Bellevue 
Medical  College;  General  Medical  Officer,  Depart- 
ment of  Health,  New  York. 
"Like  all  of  your  publications,   your  recent  book 
entitled     'Tuberculosis    A    Preventable    and    Curable 
Disease,'  is  notable  because  of  its  clearness,  directness, 
anfl  simplicity  of  style.     It  seems  to  me  excellent  in 
every  respect  and  is  an  important  and  valuable  contri- 
bution to  the  propagandum  for  the  treatment  and  pre- 
vention of  tuberculosis." 


PREFACE  TO  SECOND  EDITION  xv 

Rev.  John  H.  Holmes,  Minister  of  the  Unitarian 
Church  of  the  Messiah,  New  York. 
"I  do  not  know  when  I  have  read  a  volume  of  more 
practical  value  and  one  destined  to  accomplish  more 
good.  Packed  from  cover  to  cover,  with  the  most 
important  kind  of  information,  it  ought  to  work  a 
miracle  in  the  education  of  the  public." 

A.  Jacobi,  M.  D.,  LL.  D.,  Emeritus  Professor  of  Diseases 
of  Children,  Columbia  University;  Ex-president  of 
the  N.  Y.  Academy  of  Medicine  and  of  the  Associa- 
tion of  American  Physicians. 
"Your  new  book  contains  whatever  we  now  know  of 
tuberculosis,  its  nature,  prevention  and  treatment,  in 
a  lucid  and  popular  style.     By  publishing  it  you  have 
rendered  an  important  and  pleasing  service." 

Theodore  C.  Janeway,  Ph.  B.,  M.  D.,  Professor  of 
Medicine,  Columbia  University;  Attending  Physi- 
cian, St.  Luke's  Hospital,  New  York. 
"It  seems  to  me  you  have  put  between  the  covers  of 
your  book  practically  everything  of  importance  for  the 
general  practitioner  and  the  intelligent  layman,  who 
wishes  to  take  his  part  in  the  anti-tuberculosis  campaign. 
For   the   former   your   pages — one   might   almost   say 
sermon — on  the  Physician's  Duty  ought  to  be  of  the 
greatest  value,  if  he  has  not  given  the  subject  much 
thought,  in  setting  before  him  clearly  the  great  responsi- 
bility to  other  individuals  and  the  community,  which 
rests  on  everyone  who  undertakes  the  treatment  of  a 
tuberculous  invahd." 


xvi  PREFACE  TO  SECOND  EDITION 

John  H.  Lowm.\x,  ]M.  D.,  Professor  of  Medicine  at 
the  Western  Reserve  University,  Cleveland,  Ohio. 
"The  author  of  this  book  has  the  art  of  putting 
plain  questions  plainly  and  of  appealing  to  the  practical 
sense  of  a  people.  That  Dr.  Knopf  has  put  his  heart 
as  well  as  his  mind  in  his  work  is  shown  by  the  evident 
sincerity  and  purpose  of  his  work.  The  book  is  an 
appeal  and  it  cannot  fail  of  its  object." 

George  M.  Kober,  M.  D.,  Professor  of  Hygiene, 
University  of  Georgetown,  Washington,  D.  C. 
"Professor  Knopf  has  shown  that  tuberculosis  is  a 
preventable  and  curable  disease — we  firmly  believe 
that  if  the  measures  recommended  by  him  in  his  book 
were  generally  adopted,  the  '  great  white  plague '  which 
now  carries  off  annually  over  150,000  victims  in  the 
United  States  alone  would  be  eradicated  within  one 
or  two  generations." 

Edward  O.  Otis,  A.  B.,  M.  D.,  Professor  of  Pulmon- 
ary   Diseases    and    Climatology,    Tufts    Medical 
College,  Boston,  Mass.;  Visiting  Physician  to  the 
Massachusetts  State  Hospital  for  Consumptives. 
"You  have  not  only  discussed  the  whole  subject  of 
tuberculosis,  but  have,  as  well,  considered  innumerable 
social  conditions  which  predispose  to  the  disease  as 
well  as  their  remedy;  indeed  the  book  can  almost  be 
considered  a  treatise  on  healthy  living." 

W.  S.  Thayer,  A.  B.,  M.  D.,  Professor  of  Medicine, 
Johns  Hopkins  University;  Physician  to  Johns 
Hopkins  Hospital,  Baltimore,  Md, 


PREFACE  TO  SECOND  EDITION  x\'ii 

"Such  a  book  as  this  is  sure  to  be  of  real  great  value 
to  the  public,  medical  and  non-medical.  One  of  its 
great  values,  it  seems  to  me,  Kes  in  the  fact  that  it  is 
not  the  compilation,  but  the  authoritative  statement 
of  one  who  has  given  his  Hfe  to  the  study  of  this 
subject." 

Edward  L.  Trudeau,  A.  M.,  M.  D.,  Founder  and 
Physician  of  the  Adirondack  Cottage  Sanatorium, 
Trudeau,  N.  Y.;  First  President  of  the  National 
Association  for  the  Study  and  Prevention  of  Tu- 
berculosis. 
''This  book  has  a  great  field  of  usefulness  in  the 
education,  specially  of  patients,  of  the  public,  and  of 
the  general  practitioner.     As  an  educational  factor 
it  will  aid  greatly  the  antituberculosis  crusade  in  Amer- 
ica, and  I  congratulate  you  on  the  accompKshment  of 
so  thorough  and  useful  a  work." 

I  have  all  reason  to  believe  and  to  hope  that 
this  second  edition  will  meet  with  the  success  equal 
to  that  of  the  first  and  thus  not  fail  to  fulfil  its  mis- 
sion in  helping  toward  the  goal  which  I  inscribe  in 
my  dedication,  The  Eradication  of  the  Great 
White  Plague. 

S.  A.  KNOPF. 

New  York, 
April,   1910. 


PREFACE  TO  FIRST  EDITION 

In  presenting  this  new  volume  to  the  English- 
speaking  public,  and  to  the  people  of  the  United 
States  more  especially,  the  author  wishes  to  make 
clear  its  objects  and  aims.  The  book  is  intended 
to  be  helpful,  first,  to  the  patient  afflicted  with  a 
tuberculous  disease,  but  not  with  a  view  of  re- 
placing the  physician,  the  direct  m.edical  adviser; 
for  no  book,  not  even  a  scientific  treatise,  can 
replace  for  the  patient  the  experience  and  judg- 
ment of  the  skilled  physician.  But  it  will  aid  the 
sufferer  by  giving  him  such  insight  into  his  afflic- 
tion as  will  convince  him  of  the  curability  of  the 
disease  in  the  earlier  stages  and  the  great  possibil- 
ity of  improving  his  condition  in  the  latter  stages, 
providing  he  places  himself  under  the  careful 
guidance  of  a  physician  in  his  own  hygienically  ar- 
ranged home,  in  a  health  resort,  or  in  a  special  in- 
stitution (sanatorium  or  hospital). 

To  the  patient  and  those  living  with  him,  the 
book  is  intended  to  teach  the  most  efficacious  yet 
most  simple  and  practical  means  of  preventing 
the  spread  of  the  disease — in  other  words,  to  teach 


XX  PREFACE 

him  and  those  with  whom  he  comes  in  contact 
how  infecting  others  can  be  prevented  and  he 
himself  can  be  guarded  against  reinfection. 

Again,  to  those  living  and  associating  with  the 
tuberculous,  the  book  is  intended  to  give  the  as- 
surance that  the  clean,  conscientious  consumptive 
who  is  careful  in  the  disposal  of  his  sputum  and 
the  prevention  of  droplet  infection,  is  as  safe  an 
individual  to  associate  with  as  anybody  else,  and 
that  phthisiophobia  (exaggerated  fear  of  the  pres- 
ence of  a  consumptive)  is  unjustified,  cruel,  and 
inhumane. 

To  the  physician,  it  is  hoped,  that  the  book  may 
be  helpful  by  enabling  him  to  give  to  his  tuber- 
culous patients  in  detail  the  necessary  instructions 
concerning  their  duties  to  themselves,  to  their 
friends  and  families,  to  their  medical  advisers,  and 
to  the  community  in  which  they  may  live. 

To  the  physician,  nurse,  and  family  of  the  pa- 
tient, the  descriptions  and  illustrations  of  some 
devices  whereby  the  open  air  treatment  and  other 
hygienic  and  sanitary  installations  in  the  home  of 
the  patient  can  be  easily  arranged,  it  is  hoped, 
may  likewise  be  helpful. 

To  the  hygienist  and  sanitarian,  the  hints 
which  the  book  contains  concerning  the  housing 
problem  in  its  relation  to  the  prevention  of  tuber- 
culosis may  not  be  amiss. 


PREFACE 


XXI 


To  municipal  and  health  authorities  of  cities 
and  towns  wherein  the  compulsory  notification  of 
tuberculous  cases  and  the  proper  control  of  tuber- 
culosis is  not  yet  inaugurated,  a  description  of 
such  methods  as  have  proved  most  efficacious  will 
surely  be  welcome.  The  book  is  designed  to  be 
helpful  to  all  those  interested  in  this  phase  of  anti- 
tuberculosis work. 

To  the  city  fathers,  legislators,  and  statesmen,  it 
is  hoped  this  little  work  will  show  that  the  aboli- 
tion of  child  and  sweatshop  labor,  the  regulation 
of  woman  labor,  proper  labor  and  factory  laws  in 
general,  and  the  enactment  and  enforcement  of 
proper  bovine  laws  are  indispensable  in  the  com- 
bat of  tuberculosis.  It  will  also  show  that  to  take 
care  of  the  tuberculous  poor  at  the  right  time  and 
right  place  is  wiser  than  to  keep  them  at  the  wrong 
place  when  it  is  too  late  to  do  them  any  good ;  and 
that  by  pursuing  the  policy  outlined  herein,  the 
community  will  in  the  end  be  the  financial  gainer, 
and  the  sanitary  and  moral  conditions  of  its  citizens 
will  be  vastly  improved.  The  author  hopes  to 
convince  the  proper  authorities  that  tuberculosis 
in  prisons,  reformatories,  and  asylums  should  be 
combated  by  the  examination,  segregation,  and 
treatment  of  those  ill  with  the  disease. 

To  the  employer  of  men  and  women,  the  factory 
owner,  the  farmer,  and  even  to  people  employing 


xxii  PREFACE 

only  servants,  the  book  is  intended  to  show  that  by 
proper  sanitation  of  workshops,  stores,  factories, 
and  sleeping  quarters,  and  by  looking  after  the 
health  of  working  people  in  general,  a  vast  amount 
of  orood  can  be  done  and  the  solution  of  the  tuber- 
culosis  problem  greatly  advanced. 

To  the  public  press,  to  professors  of  colleges,  to 
teachers  of  public  and  private  schools,  and  educa- 
tors in  general,  the  book  is  intended  to  point  out 
the  part  they  have  to  play  in  the  combat  of  tuber- 
culosis as  a  disease  of  the  masses. 

To  the  clergy,  philanthropists,  charitable  indi- 
viduals, and  charity  organizations,  it  is  hoped  to 
give  some  valuable  hints  concerning  the  best  way 
to  come  to  the  aid  of  the  consumptive  poor  without 
pauperizing  them.  Philanthropists  willing  to  aid 
the  anti-tuberculosis  cause,  will  be  shown  many 
ways  in  which  they  can  serve  their  creator  by 
serving  their  fellow-men. 

Even  people  of  moderate  means  who  are  willing 
to  help  in  the  cause  of  consumptives  may  learn  how 
they  can  be  most  useful. 

The  people  living  in  neighborhoods  where  sana- 
toria exist,  or  are  projected,  it  is  hoped  will 
be  convinced  by  the  carefully  gathered  statistics 
that  such  institutions  are  not  'a  sanitary  or  eco- 
nomic danger  to  the  neighborhood,  but  that  on 
the    contrary  the    hygienic    conditions   of  places 


PREFACE  xxiii 

where  sanatoria  are  situated  have  usually  improved 
after  the  establishment  of  such  institutions,  and 
the  economic  prosperity  of  the  community  has 
correspondingly  increased.  To  fraternal  organiza- 
tions, mutual  benefit  associations,  and  life  insur- 
ance companies,  the  author  hopes  to  show  the 
great  service  such  bodies  can  render  in  the  solution 
of  the  tuberculosis  problem. 

To  the  people  at  large,  this  volume  is  intended  to 
show  that  tuberculosis  is  a  preventable  and  curable 
disease,  rarely  directly  hereditary;  and  that  in  chil- 
dren of  tuberculous  parentage,  the  hereditary  pre- 
disposition can  be  overcome  if  they  are  properly 
raised,  and  their  physique,  particularly  the  chest, 
well  developed.  Even  a  predisposition  acquired 
after  birth  or  later  in  adult  life  can  be  successfully 
combated  by  similar  means  and  by  careful,  sober, 
and  hygienic  modes  of  life. 

By  reading  the  following  pages,  it  is  hoped  the 
layman  may  learn  that  a  sober,  proper,  and  regular 
mode  of  living  is  all  that  is  necessary  to  overcome  a 
hereditary  predisposition  or  an  acquired  tendency 
to  the  disease,  and  learn  also  what  he  is  to  do  and 
what  not  to  do  if  he  wishes  never  to  fall  a  victim 
to  tuberculosis.  By  pointing  out  the  early  symp- 
toms that  may  be  easily  recognized  by  a  layman,  it 
is  hoped  to  induce  the  individual  having  such 
symptoms  to  place  himself  under  the  care  of  a 


xxiv  PREFACE 

physician  immediately,  while  he  is  still  in  the  most 
curable  stage  of  the  disease,  and  thus  be  restored 
promptly  to  health  an^t^trength.  In  short,  it  is 
hoped  that  the  knowredge  which  this  book  is  in- 
tended to  impart  will  help  to  solve  the  tuberculosis 
problem  and  bring  us  nearer  to  the  time  when  the 
great  white  plague  shall  be  forever  eradicated  from 

our  midst. 

S.  A.  KNOPF. 

New    York, 
May,  1909. 


TABLE  OF  CONTENTS 

PAGE 

Preface  to  Second  Edition     .        .        .        .      ix 
Preface  to  First  Edition        ....    xix 

CHAPTER  I 

What  a  Tuberculous  Patient  Should  Know 

of  His  Disease 3 

Professor  Robert  Koch.  Definition  of  pulmonary 
tuberculosis.  Infectiousness  of  tuberculosis.  Dis- 
covery of  the  tubercle  bacillus.  Infection  by  inhala- 
tion. Droplet  infection.  Infection  from  food  sub- 
stances. Infection  by  inoculation.  Methods  of  pre- 
venting the  four  sources  of  infection.  Cuspidors  and 
sputum  pocket  flasks.  Danger  of  infection  by  flies. 
Useless  cough.  General  personal  hygiene.  Rational 
dress.  Advantages  of  being  acquainted  with  charac- 
ter of  the  disease.  Proofs  of  the  curability  of  tuber- 
culosis. The  importance  of  medical  guidance  and 
supervision  of  the  tuberculous  patient. 

CHAPTER  II 

What  Those  Living  with  Patients  Should 

Know  Concerning  the  Disease        .        .       16 
How  to  deal  with  tuberculous  patients.     Natural 

XXV 


xx\'i  TABLE  OF  CONTEXTS 

PAGE 

sources  of  defense  against  tuberculosis.  How  to  guard 
against  infection.  Direct  heredity.  Hereditary  pre- 
disposition. Care  of  a  child  to  prevent  post-natal  in- 
fection. Prevention  of  tuberculosis  from  milk.  Ster- 
ilization and  pasteurization  of  milk.  Care  of  personal 
and  bed  linen.  Cleaning  the  rooms  occupied  by  con- 
sumptives. The  sweeping  by  pneumatic,  exhaustive, 
or  vacuum  process.  How  to  render  the  tuberculous 
patient  cheerful.  Phthisiophobia.  Opinions  of  lead- 
ing medical  authorities  on  the  character  of  tuberculous 
invalids. 


CHAPTER  III 

The  Duties  of  the  Physician  Towards  His 
Patient,  the  Family  of  the  Patient,  the 
Community  He  Lives  in,  and  Other  Com- 
munities       29 

Individual  instruction  to  the  patient.  Hope  and 
cheerfulness.  Leaflets  of  instruction,  Inauguration 
of  preventive  measures.  When  to  send  the  patient 
away.  Maxims  in  choice  of  cHmate.  Examination 
and  periodical  reexamination  of  all  members  of  a 
family.  Selection  of  trade  or  profession  for  young  man 
or  woman  predisposed  to  tuberculosis.  Com])ulsory 
notification.  Physician's  duty  toward  the  community 
he  lives  in.  Physician's  duty  toward  other  communi- 
ties. Disinfection  of  sick  room.  Leaflet  of  general 
advice  to  tuberculous  patients.  S])ccial  advice  to 
patient,  nurse,  and  family.  The  treatment  of  the 
patient's  mind. 


TABLE  OF  CONTENTS  xxvii 


CHAPTER  IV 


PAGE 


How  THE  Sanatorium  Treatment  May  Be 
Adapted  to  and  Imitated  in  the  Home 
OF  THE  Consumptive  .        .        .        -56 

Sanatorium  treatment  at  home.  Proper  housing. 
Selection  and  equipment  of  bedroom.  Aerotherapy. 
Half-tent  for  the  rest  cure  in  the  open  air.  Porches 
for  outdoor  sleeping.  Description  of  Dr.  Millet's 
sleeping  shack.  Tents  for  use  in  dry  climates.  De- 
scription of  Dr.  Knopf's  window-tent.  Description  of 
Dr.  Bull's  aerarium.  Preparation  for  outdoor  sleep- 
ing in  cold  weather.  The  Klondike  bed.  How  to 
guard  against  bright  light  in  window-tent.  Sputum 
flask  in  window-tent.  Screen.  Precautions  regarding 
the  open  air  treatment.  Open  air  cure  during  the  day 
in  the  window-tent.  How  to  become  accustomed  to 
cold  douches.  Simple  arrangement  for  taking  the 
cold  douche. 

CHAPTER  V 

How  Sanitation  and  Proper  Housing  May 
Help  Toward  the  Prevention  of  Tuber- 
culosis          84 

Polluted  air  in  large  cities.  Polluted  air  in  the 
homes  of  the  poor.  Effect  of  pure  air  on  the  develop- 
ment of  the  chest.  Advantages  of  wide  streets  and 
lower  buildings.  Sanitary  effect  of  woody  regions. 
Number  of  people  employed  in  indoor  occupations 
in  the  United  States.  Time  spent  indoors  by  majority 
of  people.     Construction  of  private  houses  with  play- 


xx^'iii  TABLE  OF  CONTENTS 

PAGE 

grounds.  How  to  build  sanitary  houses.  French 
windows  recommended.  Limit  to  height  of  buildings. 
Density  of  population  in  large  cities.  Necessity  of 
rapid  transit  facilities.  Garden  cities  for  the  laboring 
population.  Short's  model  tenement  house.  De- 
scription of  an  open  air  tenement  house.  Utilization 
of  flat  roofs  in  cities.  Roof  playgrounds.  "Roof 
camping."  Description  of  an  open  air  private  dwell- 
ing. Individual  economic  sanitary  house  for  laboring 
man.  Lodging  houses.  Internal  arrangement  of 
homes.  Night  air.  Dark  and  overcrowded  bed- 
rooms. Method  of  heating.  Humidifier.  Overheated 
and  dry  atmosphere  in  houses.  Hair  hygrometer. 
Avoidance  of  dust  indoors.  Rules  for  sweeping  and 
dusting.  Traihng  skirts.  Cleaning  of  shoes.  Brush' 
ing  of  garments. 

CHAPTER  VI 

The  Duties  of  Modern  Municipal  Health 

Authorities        .  ....     126 

Smoke  nuisance  and  its  prevention.  Preventive 
measures  in  Chicago,  London,  and  Manchester.  Fire- 
less  locomotive.  Cleaning  of  streets.  Street  sprink- 
ling. Sweeping  streets.  Self-flushing  cuspidors  in 
pubh'c  buildings.  Leaflets  for  the  education  of  con- 
sumptives and  those  living  with  them.  New  York 
Health  Department's  short  general  circulars  for  the 
laity.  Circular  to  j^hysicians.  Permanent  tuljer- 
culosis  exhibitions.  Lantern  exhibits.  Municipal 
control  of  tuberculosis.  Object  of  tuberculosis  disj^en- 
saries.      Location  and  construction  of  ideal   dispen- 


TABLE  OF  CONTENTS  xxix 

PAGE 

sary.  Description  of  New  York  Health  Department's 
clinic.  Avoidance  of  multiplication  of  efforts.  Pro- 
vision for  the  family  of  the  tuberculous  breadwinner. 
Municipal  sanatoria  and  special  hospitals  for  tubercu- 
lous adults  and  children.  Tuberculosis  in  almshouses 
and  orphan  asylums.  Chain  of  institutions.  Police 
power  of  the  Health  Department.  Financial  and 
moral  gain  to  a  community  which  cares  for  its  con- 
sumptive poor.  Municipal  baths,  parks,  and  play- 
grounds. Hygienic  city  offices.  Examination  for 
tuberculosis  of  all  city  employees.  Exclusion  from 
indoor  work  of  all  tuberculous  city  employees.  Civil 
service  examination  and  tuberculosis.  Inspection  of 
milk.  Badly  ventilated  public  meeting  places.  Ex- 
clusion of  tuberculous  employees  from  occupations 
involving  handling  of  food. 

CHAPTER  VII 

The  Duties  of  State  and  Federal  Authori- 
ties IN  THE  Combat  of  Tuberculosis  .  171 
Collaboration  between  State  and  municipal  authori- 
ties. Advantage  of  sanatoria  in  home  climates.  Lo- 
cation of  State  sanatoria.  How  to  avoid  pauperi- 
zation. Results  obtained  in  Massachusetts  State 
Sanatorium.  List  and  descriptions  of  State  sanatoria 
in  the  United  States.  State  sanatoria  in  construction 
or  projected.  Number  of  tuberculosis  dispensaries  in 
the  United  States.  Tuberculosis  in  insane  asylums 
and  prisons.  Tuberculous  prisoners  in  detention  pris- 
ons. Tuberculosis  in  penal  institutions.  Rules  for 
prevention  of  tuberculosis  in  prisons.    Infection.    Dis- 


XXX  TABLE  OF  CONTENTS 

PAGE 

infection  of  clothes,  blankets,  etc.,  in  prisons.  Venti- 
lation and  lighting.  Frankel's  mouth-mask.  Danger 
from  whitewash.  Exercise  for  prisoners.  Bathing  and 
food.  Effect  of  overwork  on  the  predisposed  prisoners. 
Overcrowding  in  badly-ventilated  workshops.  Dan- 
gerous occupations.  Discharge  of  tuberculous  pris- 
oners. Agricultural  colonies  for  tuberculous  prisoners. 
Wynne  State  Farm.  Woman's  labor,  child  labor, 
sweatshop  labor.  Sanitary  supervision  of  factories. 
Bovine  tuberculosis.  Uniform  bovine  laws.  Tuber- 
culosis in  United  States  Army  and  Navy.  Tubercu- 
losis in  non-military  government  services.  Tuber- 
culosis in  post  offices.  Cleaning  and  disinfecting 
United  States  mail  bags.  Government  sanatorium 
for  non-military  tuberculous  employees.  Emigration 
from  city  to  country.  Schools  of  forestry.  Co- 
operation of  municipal  and  State  authorities  with 
Federal  Department  of  Health.  President  Taft  on  a 
new  Public  Health  Bureau. 

CHAPTER  VIII 

What  Employers  of  Every  Kind  Can  Do  to 
Diminish  Tuberculosis  Among  the  Men 
AND  Women  Working  for  Them        .        .228 
Factory  and  office  hygiene.     Spitting  regulations. 
Danger  of    overheating.      Dn)j)let   infection.     Indis- 
criminate ex[;ectoration.     Examination  and  reexam- 
ination of    all   emjjloyecs.     Lectures   to    employees. 
Emjjloyer's  duty  toward  family  of  the    tuberculous 
emjjloyee.     Tuberculous  miners.     Tuberculous  serv- 
ants.    Telephone  hygiene.      Duties  of  railroad  cor- 


TABLE  OF  CONTENTS  xxxi 


PAGE 


porations.  Cleaning  of  cars.  General  railway  sanita- 
tion. Tuberculosis  among  telegraph  and  telephone 
operators.  Farmer's  duty  in  the  prevention  of  tuber- 
culosis in  man  and  beast.  Tuberculin  test  in  cattle. 
Tuberculosis  in  horses,  swine,  goats,  dogs,  and  par- 
rots.   Prevention  of  tuberculosis  among  sailors. 

CHAPTER  IX 

The  Duties  of  School  Teachers,  Educators 
IN  General  and  of  the  Public  Press  in 
THE  Combat  of  Tuberculosis  .  .  .  246 
Prevention  of  tuberculosis  in  pubHc  schools.  Con- 
struction and  equipment  of  schools.  Playgrounds, 
roof  gardens,  swimming  tanks.  Swimming  lessons. 
Respiratory  exercises  for  school  children.  Outdoor 
instructions.  School  hours  and  home  lessons.  Age 
at  which  a  predisposed  child  should  attend  school. 
Description  of  Dr.  Knopf's  breathing  exercises.  Sing- 
ing and  recitation  in  the  open  air.  Excursions  to  the 
country.  School  farms.  Malnutrition  of  school  chil- 
dren. Free  luncheons  for  children  of  the  poor.  In- 
struction of  all  pupils  in  the  prevention  of  tubercu- 
losis. Alphabet  for  school  children  in  the  prevention 
of  tuberculosis.  Early  signs  of  various  forms  of  tuber- 
culosis in  children  which  teachers  should  be  able  to 
recognize.  Scrofulous  children.  Examination  of  all 
children  entering  school.  Open  air  school  for  tuber- 
culous and  predisposed  children.  Description  of 
Providence  open  air  school.  Open  air  school  for 
tuberculous  children  on  the  "Southfield"  in  New 
York..    Open  air  schools  for  well  children.     Seaside 


xxxii  TABLE  OF  CONTENTS 

PAGE 

sanatoria  for  tuberculous  children.  School  sanatoria 
for  tuberculous  teachers.  Teaching  of  prophylaxis  of 
tuberculosis  in  colleges,  etc.  Evening  lectures  under 
the  auspices  of  the  Board  of  Education.  Anti-tuber- 
culosis education  through  the  public  press.  "Sure 
consumption  cure"  advertisements.  Cooking  schools 
and  housekeeping  centers.  "Carohne  Rest"  school 
sanatorium  for  mothers.  Practical  housekeeping 
centers.     Unwise  Antagonism  to  Authorities. 

CHAPTER  X 

The  Duty  of  the  Clergy,  Philanthropists, 
Charitable    Individuals,  and    Charity 

Organizations 284 

Duties  of  the  clergy  in  the  prevention  of  tubercu- 
losis. Church  hygiene.  Disinfection  of  objects  of  ad- 
oration. Ritual  circumcision.  Individual  commun- 
ion cups  and  sanitary  common  communion  cup. 
Anti-tuberculosis  sermons.  Denominational  hospi- 
tals for  the  care  of  the  tuberculous.  Cremation. 
Expensive  Funerals.  Anti-tuberculosis  work  of  the 
Emmanuel  Church.  Co-operation  to  form  a  spe- 
cial tuberculosis  committee.  Purpose  of  a  tuber- 
culosis committee.  Work  accomplished  by  the 
New  York  Charity  Organization  Society  Tubercu- 
losis Committee.  Need  of  sanatoria  for  tuberculous 
children.  Value  of  sanatorium  treatment.  Diet- 
kitchen  association.  Anti-tuberculosis  work  by  phi- 
lanthropists. Animal  experimentation  and  vivisec- 
tionists.  Number  of  sanatoria  in  the  United  States. 
Illustrations   of  different   types   of  sanatoria   of  the 


TABLE  OF  CONTENTS  xxxiii 


PAGE 


United  States,  Canada,  and  Europe.  Social  and  medi- 
cal mission  of  the  sanatorium.  Influence  of  the  sana- 
torium on  private  and  official  phthisiophobia.  Mor- 
tality statistics  of  localities  near  sanatoria.  Sanatoria 
as  educational  factors  to  physicians  and  nurses.  The 
alcohol  question  in  the  sanatorium.  Intellectual  and 
educational  advantages  for  sanatorium  inmates. 
Philanthropic  consumptives.  Day  camps  and  night 
camps.  Dr.  Richer's  preventorium.  Class  method 
feasible  in  sanitary  tenement.  The  Shively  sanitary 
tenement.  Institutional  segregation  of  advanced 
cases. 

CHAPTER  XI 

The  Duties  of  the  People  in  the  Combat 

OF  Tuberculosis  .  .  .  .  .351 
Early  signs  of  pulmonary  tuberculosis  recognizable 
by  the  layman.  Education  through  free  lectures  and 
literature.  Overcoming  an  inherited  tuberculous 
predisposition.  Early  prophylactic  measures.  Hy- 
giene for  pregnant  women.  Hygiene  in  nursery. 
Dress  and  hygiene  for  children.  Dress  for  girls  pre- 
disposed to  tuberculosis.  Tight  lacing.  Child  labor 
at  home.  Alcoholism  as  a  predisposing  factor  and  its 
prevention.  Prohibition.  Gothenburg  system.  Re- 
sults of  treating  habit.  Education  a  remedy  for  in- 
temperance. Institutions  for  the  cure  of  habitual 
drunkards.  Healthful  amusements.  Misery  begets 
alcoholism.  Model  tenement  homes.  Comfort  sta- 
tions. Hygiene  in  workshops  and  at  home.  Value  of 
econornical  and  practical  housekeeping.    The  housefly 


xxxiv  TABLE  OF  CONTEXTS 

PAGE 

as  a  propagator  of  disease.  Open  air  life  for  every- 
body. American  National  Red  Cross  anti-tubercu- 
losis work.  Number  of  anti-tuberculosis  committees, 
societies,  and  associations  in  the  United  States.  Sana- 
toria of  fraternal  organizations.  Insurance  against 
tuberculosis. 

CHAPTER  XII 

Prospect  of  Ultimate  Eradication  of  Tuber- 
culosis          379 

Louis  Pasteur  and  his  encouraging  and  inspiring 
words.  How  tuberculosis  can  be  eradicated.  Pre- 
vention of  tuberculosis  and  of  social  misery. 


ILLUSTRATIONS 

FIG.   NO.  PAGE 

1.  Professor    Robert  Koch,  discoverer   of  the    tubercle 

bacillus  (from  his  latest  photograph)         .         Frontispiece 

2.  A  small  particle  of  sputum  seen  through  the  micro- 

scope. The  red  marks  represent  the  tuberculosis 
germs  1,200  times  enlarged     .....         4 

3.  Knopf's  cuspidor  of  metal.    It  has  a  large  opening  and 

the  cover  is  to  be  manipulated  by  the  foot.  To 
avoid  spattering  it  should  be  partially  filled  vt'ith  wet 
sawdust  ........         7 

4.  The  same  when  closed       ......         7 

5.  Sanitary    elevated    cuspidor   of   gold-bronzed   metal 

When  in  use    ........         8 

6.  Sanitary    elevated    cuspidor   of   gold -bronzed   metal 

When  closed 

7.  Knopf's  oval,  nickel-plated,  irreversible  flask  for  pocket 

use,  with  removable  funnel  that  can  be  manipulated 
with  one  hand        .......         9 

8.  Metal  sputum  flask  in  use  in  the  U.  S.  Marine  Hospital 

Service    .........       10 

9.  Dettweiler's  pocket  sputum  flask  of  thick  blue  glass, 

with  metal  mountings      .  .         .         .         .10 

10.  Kny-Scheerer  Sanitas  cup  for  pocket  use  made  of  tin 

with  a  removable  pasteboard  container     .         .         .11 

11.  Johnson  &  Johnson's  pasteboard  purse  for  sputum       11 

12.  Seabury  &  Johnson's  metallic  frame  for  pasteboard 

sputum  cup     .         .         .         .         .         .         .         .12 

13.  Pasteboard  container  to  Seabur}-  &  Johnson's  cup     .       12 

14.  Sanitary   spitcup  made   of  pressed  pasteboard  with 

cover  and  handle     .......       13 

XXXV 


xxxvi  ILLUSTRATIONS 

FIG.   XO.  PAGE 

15.  Knopf's  half-tent  for  the   rest-cure  in  the  open  air. 

The  detachable  cover  is  made  of  sail  canvas.    When 

not  in  use  the  frame  may  be  folded  flat     ...       58 

16.  Sleeping  balcony  designed  and  used  by  a  young  tuber- 

culous chemist  of  Boston         .....       60 

17.  Original  sleeping  balcony  in  Hanover,   ]\Jass.,   used 

since  June,  1898      .......       62 

18.  Latest  model  of  sleeping  shack  designed  by  Dr.  Millet 

of  Brockton,   Mass.        ......  63 

19.  Plans  of  Dr.  Millet's  shack.     South  and  east  elevations  63 

20.  The  Tucker  tent  for  outdoor  living     ....  66 

21.  Knopf's  window-tent  for  the  open  air  treatment  of 

tuberculous  patients.  Tent  in  use  with  patient  in 
bed  looking  through  the  celluloid  window  into  the 
room,  but  breathing  outdoor  air  only.       ...       67 

22.  Sectional   view   showing   the   ventilation   of   Knopf's 

window  tent    ........       68 

23.  View  of  the  window-tent  and  patient  taken  from  the 

outside 70 

24.  Knopf's  window-tent  raised,  when  not  in  use       .         .  71 

25.  Bull's  aerarium  for  the  open  air  treatment  •  •  •  75 
25a.  Sectional  view  of  Bull's  aerarium     ....  75 

26.  How  to  dress  for  outdoor  sleeping  in  cold  weather     .  76 

27.  Children  at  play  on  the  roof  of  a  private  house  in  New 

York  City        ....  ...       92 

28.  R.  Thomas  Short's  prize  plan  for  a  model  tenement 

house       .........  95 

29.  Elevation  of  open  air  model  tenement  house         .         .  97 

30.  Plan  for  open  air  model  tenement  house     ...  99 

31.  Group  of  children,  operated  on  for  surgical  tubercu- 

losis, at  play  on  the  roof  of  the  N.  Y.  Post-Graduate 

Medical  School 104 

32.  Roof  camping  in  midsummer  in  New  York  .  .  105 
33-  Open  air  i>rivate  dwelling  (elevation)  .  .  .  .  108 
34.  First  floor  plan  of  private  open  air  dwelling        .         .  109 


ILLUSTRATIONS  xxxvii 

FIG.  NO.  PAGE 

35.  Second  floor  plan  of  private  open  air  dwelling    .         .110 

36.  Economical  sanitary  house  for  one  family    .         .         .112 

37.  First  floor  plan  of  economical  sanitary  house  for  one 

family      .         .         .         .         .         .         .         .         -113 

^8.  Second  floor  plan  of  economical  sanitary  house  for  one 

family      .         .         .         .         .         .         .         .         .114 

39.  Barnes'  Humidifier     .......     122 

40.  Direct  reading  hair-hygrometer  to  determine  humidity 

in  rooms  ........     123 

41.  Knopf's  elevated  self-cleaning  street  and  garden  spit- 

toon        .........     132 

42.  Knopf -Thiebert  self -flushing  elevated  cuspidor  with 

cover  for  railway  stations,  etc.       ....     132 

43.  A  section  of  the  International  Tuberculosis  Exhibit 

held  in  New  York,  January,  1909,  at  the  Museum 
of  Natural  History,  showing  exhibits  of  various 
States  and  countries       ......     144 

44.  New   York    State   section   of  the   International   Ex- 

hibit      145 

45.  New  forms  of  shelter  for  consumptive  cases  as  exhib- 

ited at  the  Dublin  Tuberculosis  Exhibition       .         .146 

46.  Plan  of  Tuberculosis  Clinic  of  the  N.  Y.  Health  De- 

partment ........     153 

47.  A  porch  of  the  Seabreeze  Sanatorium  for  Children 

suffering  with  surgical  tuberculosis  at  Coney  Island, 
N.  Y.  Established  by  the  Society  for  the  Improve- 
ment of  the  Condition  of  the  Poor,  now  maintained 
by  Mr.  John  D.  Rockefeller 158 

48.  Inland  Sanatorium.     Countrv^  branch  of   the  N.  Y. 

Orthopaedic  Dispensary  and  Hospital  at  White 
Plains,  N.  Y.  Acute  cases  of  joint  tuberculosis 
"doing  cures"   in  midwinter  ....     159 

49.  Patients  taking  breathing  exercises  under  the  direction 

of  the  physicians  at  Riverside  Hospital  Sanatorium 

of  the  N.  Y.  Health  Department     ....     162 


XXXVIU 


ILLUSTRATIONS 


51- 


52. 


53- 

54- 

55- 
56. 

57- 

58- 


FIG.   NO.  PAGE 

50.  Boys  without  a  playground  .....  165 
First  State  Sanatorium  erected  in  the  United  States, 

located  at  Rutland,  Mass.  .  .  .  .  -174 
Patients    of    the    Massachusetts    State     Sanatorium 

taking  the  open  air  cure  at  a   temperature  below 

zero  .         .         .         .         .         .         .         .         .176 

Winter  view  of  the  N.  Y.  State  Hospital  for  Incipient 

Tuberculosis  at  Ray  Brook,  N.  Y 188 

Rhode  Island  State  Sanatorium,  situated  at  Wallum 

Lake,  R.  1 193 

Proedohl's  iron  spittoon  for  use  in  workshops     .         .     202 

Frankel's  mouth  mask 206 

Plan  of  station  for  cleaning  and  disinfecting  post-office 

mail  bags         ........     224 

Hygienic  device  for  telephone  transmitter     .         .         .     235 

59.  Roof  playground  of  Public  School  No.  44,  New  York 

City 247 

60.  Schoolgirls  learning  to  swim  at  Corlear  Street  Public 

Bath,  New  York  City 249 

61.  Respiratory  Exercise  A 253 

62.  Respiratory  Exercise  B 254 

63.  Respiratory  Exercise  C 255 

64.  Respiratory  Exercise  D 255 

65.  Respiratory  Exercise  E  .....         .  256 

66.  Respiratory  Exercise  F 257 

67.  Respiratory  Exercise  G 258 

68.  Children's  School  Farm  at 

Eleventh  Avenue  and  F 
City,  where  children  crippled  by  tuberculosis  or  ac- 
cidents are  taken  during  the  daytime  for  play  and 
in.struction  in  farming  and  gardening.  Mrs.  Henr>' 
Parsons,   founder  anrl  director        ....     262 

6g.  Open  air  .school  at  Providence,  R.  1 270 

70.  London   City  Council  open  air  school   at   iiorniman 

Park — Resting  time 271 


the  DeWitt  Clinton  Park, 
ifty-fourth  St.,  New  York 


ILLUSTRATIONS  ^xxix 

FIG.  NO.  PAGE 

71.  Open  air   school  on   the    "Southfield,"    a   discarded 

ferryboat  anchored  at  foot  of  East  Twenty-sixth 
Street,  New  York  City     .         .         .         .         .         .272 

72.  Seaside  sanatorium  and  school  for  the  tuberculous 

children  of  the  city  of  Paris,  located  at  Berck-sur- 
Mer 277 

73.  Playground  in  midwinter  for  tuberculous  children  at 

Seabreeze,  Coney  Island,  N.  Y.      .         .         .         .278 

74.  Rev.  Ljunggren's  hygienic  chalice      ....     288 

75.  The  Philadelphia  Protestant  Episcopal  City  Mission 

House  for  Consumptives,  founded  in  1877       .         .     290 

76.  St.  Joseph  Hospital  for  Consumptives  in  all  stages  of 

the  disease,  New  York  City 291 

77.  Nazareth  Branch  of  Seton  Hospital  for  consumptive 

women  and  children,  in  charge  of  the  Roman  Catho- 
lic Sisters  of  Charity 292 

78.  The  National  Jewish  Hospital  for  Consumptives  at 

Denver,  Colo.,  men's  pavilion.  Only  incipient 
cases   are   admitted 293 

79.  The  National  Jewish  Hospital  for  Consumptives  at 

Denver,  Colo.  The  balconies  of  the  circular  pa- 
vilion for  women     .......     294 

80.  An  Emmanuel  Church  class  patient  taking  the  open 

air  treatment  in  a  back  yard  of  a  Boston  tene- 
ment         302 

81.  Panoramic  view  of  the  Adirondack    Cottage   Sana- 

torium, Trudeau,  N.  Y.  For  incipient  and  early 
cases.  Semi-philanthropic.  The  uniform  charge  is 
$5.00  per  week       .......     314 

82.  Adirondack  Cottage  Sanatorium.     Piazza  of  the  new 

Medical  and  Reception  Pavilion     .         .         .         .316 

83.  Marilla  C.  Wheeler  Cottage  of  the  Adirondack  Cot- 

tage Sanatorium,  at  Trudeau,  N.  Y.      .         ,         -317 

84.  Adirondack   Cottage  Sanatorium.     Ground  Plan  of 

McAlpin  Cottage 318 


xl  ILLUSTRATIONS 

FIG.   NO,  PAGE 

85.  Agnes  Memorial  Sanatorium,  Denver,  Colo.     Sleep- 

ing gallery  for  women •     3'^9 

86.  Agnes  Memorial  Sanatorium,  Denver,   Colo.     Male 

patients  taking  the  open  air  rest  cure      .         .         .     320 

87.  Bariow     Sanatorium,     Los    Angeles,     Cal.       Semi- 

philanthropic.    Rates:  $5.00  to  $7.00  for  those  who 

are  able  to  pay.    Others  are  cared  for  free  of  charge     322 

88.  Edward  Sanatorium  at  Naperville,  near  Chicago.    For 

incipient  cases  only.  Rates:  $10.00  per  week.  Ten 
free  beds  are  maintained  by  the  Chicago  Visiting 
Nurse  Association   .......     324 

89.  Gaylord  Farm  Sanatorium,  Wallingford,  Conn.    Semi- 

philanthropic.  Rates:  $7.00  per  week.  The  State 
appropriates  $7,500  annually.  Deficit  made  up  by 
voluntar}'  subscriptions    ......     325 

90.  Loomis  Sanatorium  at  Liberty,  N.  Y.     Sanatorium 

proper.    Private.    Rates:  $15.00  to  $40.00  per  week     326 

91.  Sleeping  porch,  Mary  Lewis  Reception  Hospital  of 

Loomis   Sanatorium        ......     328 

92.  Rest-a-While    and    original    lean-to,    Loomis    Sana- 

torium Annex  for  intermediate  division.  Rates: 
$10.00  to  $12.00  per  week.  There  is  also  a  semi- 
philanthropic  division  for  early  cases  only:  $5.00 
per  week  ........     330 

93.  Patients  at  the   Loomis   Sanatorium  exercising  just 

sufficiently  to  help  along  the  cure     ....     332 

94.  New  Mexico  Cottage  Sanatorium,  Silver  City,  N.  Mex. 

Private.    For  pulmonary  and  laryngeal  tuberculosis 

at  curable  stage.    Rate:  $83.00  per  month       .         .     ;^;^^ 

95.  Nordrach  Ranch  Sanatorium,  Colorado  Springs.    For 

the  first  and  second  stages.    Private.    Rates:  $60.00 

to  $65.00  per  month       ......     334 

96.  The  Sharon  Sanatorium;  eighteen  miles  from  Boston. 

Semi-philanthropic.  Rates:  $5.00  ])er  week.  For 
women  of  limited  means 335 


ILLUSTRATIONS  xli 

FIG.   NO.  PAGE 

97.  A  two   room  compartment  tent  of  the  Star  Ranch, 

Colorado  Springs     .......     336 

98.  Muskoka  Cottage  Sanatorium,  Gravenhurst,  Canada. 

Rates:  $12.00  to  $15.00  per  week.  Established 
through  private  gifts.  Maintained  by  the  fees  from 
patients  and  a  small  grant  from  the  Provincial 
Government    ........     337 

99.  Red  Cross  Day  Camp  on  the  roof  of  the  Vanderbilt 

Clinic      .........     338 

100.  View    of    Davosplatz,    Switzerland,    where    numer- 
ous   private    and    philanthropic    sanatoria    are  lo- 
cated        .........     339 

loi.  Sanatorium  Falkenstein,  near  Frankfort  on  the  Main, 
Germany,  with  ruin  of  Falkenstein  Castle  in  the 
background.      (Private.)  .....     340 

102.  Sanatorium  Wehrawald  and  the  village  of  Todtmoos, 

in  the  Black  Forest,  Germany.     (Private.)       .         .     341 

103.  Dr.    Weicker's     Sanatorium    in    Goerbersdorf,    near 

Breslau,   Germany.     (Private.)        ....     343 

104.  Royal  Hospital  for  Consumptives  at  Ventnor,  Isle  of 

Wight,  England 345 

105.  The    Proposed    Shively   Sanitary  Tenements;    street 

view.  Built  by  Mrs.  Wm.  K. Vanderbilt,  Sr.  Henry 
Atterbury  Smith,  Architect 346 

106.  The  proposed  Shively  Sanitary  Tenements;  court  view, 

showing   open   staircases         .....  348 

107.  Situation  of  vital  organs  in  a  normal  chest         .         .  359 

108.  Situation  of  vital  organs  in  constricted  chest         .         ,  359 

109.  Skeleton  of  chest,  permanently  constricted  by  too  tight 

lacing 359 

no.  American    National  Red  Cross    Stamp    for  the  year 

1908         .         .         .         .         .         .         .         .         -370 

III.  Proposed  quarters  of  the  National  Pythian  Sana- 
torium, Las  Vegas,  N.  Mex.  1,300  acres  have  been 
donated  to  this  institution 373 


xlii  ILLUSTRATIONS 

FIG.    XO.  PAGE 

112.  Union   Printers'    Home   for   Consumptives.      Estab- 

lished and  maintained  by  the  International  Typo- 
graphical Union 374 

113.  "  Krankenheim "  of  Dr.  H.  Weicker  at  Goerbersdorf, 

Germany,  to  which  life  insurance  companies  send 
their  tuberculous  policy  holders  immediately  after 
the  recognition  of  the  disease 375 

114.  Tuberculosis    Sanatorium    at    Oderberg,    Germany. 

Erected  by  the  State  Invalidity  Insurance  Com- 
panies for  its  tuberculous  policy  holders       .         -377 

115.  Louis  Pasteur  in  his  laboratory 380 


TUBERCULOSIS 

CHAPTER  I 

WHAT    A    TUBERCULOUS    PATIENT    SHOULD    KNOW 
OF   HIS   DISEASE 

Knowledge  is  power,  and  in  no  disease  is  the 
knowledge  of  his  condition  more  essential  for  the 
well-being  of  the  patient,  nor  is  there  any  in  which 
the  patient  can  by  this  knowledge  help  the  phy- 
sician more  toward  obtaining  a  complete  and 
lasting  recovery  than  in  the  disease  known  as 
tuberculosis  pulmonum,  phthisis  pulmonalis,  pul- 
monary tuberculosis,  or  consumption. 

The  tuberculous  patient  should  know  that  he  is 
afflicted  with  a  chronic,  infectious,  communicable, 
preventable,  and  curable  disease.  The  disease 
being  of  a  chronic  character,  that  is  to  say  long 
lasting,  the  patient  must  not  expect  to  get  well 
within  a  few  weeks.  It  may  take  months  and 
sometimes  even  years  for  a  complete  recovery. 
Fortunately,  in  many  cases  the  treatment  can  be 
continued  later  on  while  the  patient  may  be  able 
to  do  some  work  at  the  same  time. 


4  TUBERCULOSIS 

The  tuberculous  patient  must,  on  account  of 
the  nature  of  his  disease,  be  exceedingly  care- 
ful not  to  infect  others  or  reinfect  himself.  Per- 
haps the  most  frequent  cause  of  infection  is  the 
careless  disposal  of  sputum  or  spittle  containing 
the  germs  of  tuberculosis  which  can  be  transmitted 
or  communicated  from  man  to  man,  from  beast  to 
man,  and  from  man  to  beast.  It  must  be  remem- 
bered that  the  germ  of  tuberculosis,  called  bacillus 
tuberculosis  and  discovered  by  Professor  Robert 
Koch  in  1882  {Frontispiece),  is  the  only  direct 
cause  of  all  tuberculous  diseases,  and  that  without 
the  presence  of  this  bacillus  the  development  of 
tuberculosis  is  impossible.  Koch  called  this  germ 
''bacillus,"  which  is  the  Latin  for  rod,  because 
under  a  powerful  microscope,  when  subjected  to 
a  certain  red  coloring  agent,  these  minute  forms 
appear  like  little  rods.  (Fig.  2.)  When  these 
germs  enter  any  living  organism  they  are  apt  to 
multiply  and  by  irritation  cause  the  growth  of 
small  elevations  about  the  size  of  the  head  of  a 
pin,  called  tubercles,  hence  the  name  tuberculosis. 

The  bacilli  may  be  found  in  countless  numbers 
in  the  lung  or  any  other  organ  affected  with 
tuberculosis,  and  in  the  case  of  pulmonary  con- 
sumption quantities  of  them  arc  rejected  when  the 
patient  expectorates.  The  bacillus  or  germ  of 
tuberculosis  is  a  little  parasite,  a  fungus  or  mush- 


-f". 


X 

i'x 

■r^ 

\^ 

%#-^^ 

-^k 

.*%> 

-^■^■K 

#, 

<g<).  -^J^-.  ^i>-~ 


^' 


■i*!.' 
^if 


'4 


'"'=?^~9C: 


1^*-  v: 


^ 


> 


<l.<s. 


Fig.  2.  A  small  particle  of  Sputum  seen  through  the  Alicro- 
scop)e.  The  Red  marks  represent  the  Tuberculosis  Germs 
I200  times  enlarged. 


INFECTIOUSNESS  OF  TUBERCULOSIS         5 

room,  belonging  to  the  lowest  scale  of  vegetable 
life.  It  not  only  gradually  destroys  the  lung  sub- 
stance through  ulcerative  processes,  but  gives  off 
at  the  same  time  certain  poisonous  substances 
called  toxins  which  are  often  the  cause  of  serious 
symptoms. 

The  manner  in  which  the  infection  from  man 
to  man  occurs  most  readily  is  by  the  inhalation 
of  bacilli-laden  dust.  If,  for  example,  a  patient 
expectorates  on  a  floor  or  a  wall  where  the  sputum 
has  a  chance  to  dry  and  become  pulverized,  it 
is  liable  to  float  with  the  dust  in  the  air,  and  any 
predisposed  individual  breathing  this  air  is  in 
danger  of  contracting  the  disease  by  inhalation. 

Another  w^ay  in  which  infection  may  take  place 
is  from  close  contact  with  tuberculous  individ- 
uals who  are  not  only  careless  with  the  disposal 
of  their  expectoration,  but  also  careless  w^hen 
coughing.  It  is  erroneous  to  suppose  that  the 
patient  who  coughs  but  does  not  expectorate  is 
therefore  harmless.  He  is  only  harmless  when  he 
takes  care  always  to  hold  his  hand  or  handker- 
chief before  his  mouth  so  as  to  prevent  the  expul- 
sion of  small  particles  of  saliva  during  coughing. 
These  small  particles  or  little  drops  of  saliva  may 
contain  the  bacilli  and,  when  taken  into  the  system 
of  a  predisposed  individual  by  inhalation  or  inges- 
tion, may  cause  a  tuberculous  infection.      This 


6  TUBERCULOSIS 

manner  of  communicating  the  disease  from  one 
person  to  another  is  called  droplet  infection. 

The  next  most  frequent  way  in  which  tubercu- 
losis may  be  transmitted  to  man  is  through  the 
digestive  system.  Tuberculous  meat  or  milk  can 
give  tuberculosis  and,  according  to  some  authori- 
ties, infection  from  the  ingestion  of  tuberculous 
milk  is  quite  frequent. 

Inoculation,  that  is  to  say,  the  penetration  of 
tuberculous  substance  through  a  lacerated  skin 
or  any  other  kind  of  a  wound,  is  most  likely  to 
happen  when  proper  care  is  not  taken  in  cleaning 
cuspidors  which  have  been  used  by  consumptives. 
If  the  cuspidor  is  of  glass  or  porcelain  and  should 
be  nicked  or  chipped,  the  wound  and  the  inocula- 
tion may  occur  at  the  same  time.  Occasionally, 
physicians,  students  of  medicine,  or  veterinary 
science  become  inoculated  with  tuberculosis  by 
wounding  themselves  with  instruments  which  had 
been  soiled  with  tuberculous  matter. 

Formidable  as  these  multiple  dangers  of  infec- 
tion and  reinfection  appear,  it  should  be  said 
right  here  that  all  that  is  necessary  to  avoid  them 
is  to  be  careful,  conscientious,  and  faithful.  The 
patient  who  is  up  and  about  should  always  expec- 
torate into  a  cuspidor  partially  filled  with  water. 
The  cuspidor  should  have  a  cover  and  it  should 
have  an  opening  large  enough  for  the-  individual 


INFECTION 


using  it  to  have  no  difficulty  in  depositing  his  spittle 
in  the  interior  of  the  receptacle,  so  that  he  will  not 

soil  the  brim  on  which 
the  tuberculous  matter 
would  have  a  chance  to 
dry  and  become  a  source 
of  infection.  (Figs.  3,  4, 
5,  6.)  The  tuberculous 
patient  when  outside  of 

Fig.  3.  Knopf's  cuspidor  of  met-  ^is  homC,  should,  of 
al  It  has  a  large  opening  cOUrSe,  be  aS  rcligioUsly 
and  the  cover  is  to  be  manip-  r    i         '.a     ^  •  ± 

^  ,  A  u   .^.   (   .    rj.        ..    careiul  with  his  sputum 

ulated  by  the  foot.     To  avoid  ^ 

spattering    it    should   be    par-     aS    withiu    it.       When   he 

tiaiiy  filled  with  wet  sawdust.  ^^^  ^^^  Conveniently  ex- 
pectorate in  the  usual  type  of  cuspidor,  he  should 
not  let  this  serve  as  an  excuse  for  careless  ex- 
pectorating and  the  dissemination  of  his  disease. 
He  should  always  provide  himself  with  a  sputum 
flask  either  of  metal  (Figs.  7,  8)  or  glass  (Fig.  9), 
or  a  pasteboard  box 
(Fig.  10),  or  purse  (Fig. 
11),  which  he  can  carry 
in  his  pocket.  For  the 
patient  in  bed,  a  me- 
talhc  frame  (Fig.  12) 
containing  a  box  made  of  impermeable  paste- 
board (Fig.  13),  or  a  box  made  entirely  of  paste- 
board (Fig.  14),  may  serve  as  a  convenient  sputum 


Fig.  4.     The  Same  ^\'hen  Closed. 


TUBERCULOSIS 


receptacle.     The  contents  (sputum)  of  the  pocket 
flasks  should  be  poured  into  the  water-closet  and 

the  vessels  after- 
wards cleaned  with 
hot  water.  The 
pasteboard  recepta- 
cles may  be  thrown 
into  the  fire  with 
their  contents. 

It  is  conceivable 
and  pardonable 
that,  when  in  pub- 
lic, patients  should 
not  desire  to  make 
use  of  a  pocket 
flask  or  purse  which 
would  attract  at- 
tention to  their  mal- 
ady. The  only 
thing  such  patients 
can  do  is  to  use  squares  of  soft  muslin,  cheese 
cloth,  cheap  handkerchiefs,  or  Japanese  paper 
handkerchiefs  especially  manufactured  for  that 
purpose,  which  can  be  burned  after  use.  They 
should  also  place  in  the  pocket  in  which  they 
intend  to  put  the  soiled  cloths  a  removable  lin- 
ing of  rubber  or  other  impermea])le  material 
which  can  be  thoroughly  cleaned.    This  additional 


Fig.  5.     Sanitary  Elevated  Cuspidor  of 
Gold-bronzed  Metal.     When  in  Use. 


INFECTION 


Fig.  6. 
Cuspidor  When  Closed. 


lining  could  be  fastened  to  the  inside  of  the  ordi- 
nary pocket  by  clamps,  and  would  thus  be  of  no 

inconvenience  to  the  patient. 
A  pouch  of  vulcanized  rub- 
ber or  an  Oriental  tobacco 
pouch  may  be  used  in  place 
of  the  extra  pocket  or  lining. 
In  any  case  it  is  well  to  have 
more  than  one  of  these  pock- 
ets or  pouches  so  that  the  pa- 
tient need  never  be  without 
Sanitary  Elevated  one  wliilc  the  Other  is  being 
cleaned  and  immersed  in 
some  disinfectant  or  in  boiling  water.  Ladies 
should  divide  their  little  handbags 
or  satchels  into  two  compartments; 
one  for  the  clean  and  one  for  the 
soiled  cloths.  Of  course,  all  inva- 
lids who  use  handkerchiefs,  rags,  or 
Japanese  paper  as  receptacles  for 
expectoration,  are  in  danger  of  in- 
fecting their  hands,  which  they 
should  always  wash  thoroughly  be- 
fore touching  food.  To  expectorate 
in  a  handkerchief  and  use  the  same 
for  wiping  the  nose  exposes  the  pa- 
tient to  reinfection. 

It  should  also  be  remembered  that  the  house-fly 


Fig.  7, 
oval 


Knopf's 
nickel- 
plated  irrevers- 
ible flask  for 
pocket  use, 
with  remov- 
ab  le  f  u  nnel 
that  can  be 
m  a  n  i  p  u  1  ated 
with  one  hand. 


lO 


TUBERCULOSIS 


Fig.  8.  Metal 
sputum  flask  in 
use  in  the  U.  S. 
Marine  Hospi- 
tal Service. 


and  other  insects  are  often  the  carriers  of  tuber- 
culous infection,  and  a  vessel  of  any  kind  intended 
to  receive  tuberculous  sputum 
should  not  be  without  a  cover. 
The  fly,  for  example,  may  not  only 
carry  small  particles  of  tubercu- 
lous sputum  on  its  feet  and  then 
deposit  them  on  some  article  of 
food;  but  it  has  been  demonstrated' 
that  even  the  dead  fly  which  had 
fed  on  tuberculous  substances  is 
dangerous,  for  the  tubercle  bacilli 
have  been  found  in  the  dust  coming  from  the 
crumbled  bodies  of  dead  flies. 

A  tuberculous  patient  should  be  careful  not 
to  kiss  any  one,  particularly  not 
on  the  mouth.  He  should  have 
his  own  room  if  it  is  at  all  pos- 
sible, but  always  his  own  bed.  If 
there  must  be  more  than  one  bed 
in  the  room,  they  should  be  a 
little  more  than  three  feet  apart  to  i-io.  9.  Dettweii- 
avoid  direct  droplet  infection.    The      ^^rs  poc  et  spu- 

^  t  u  m     1 1  a  s  k    o  I 

droplets  expelled  during  the  cough      thic  k  blue  glass, 
rarely  go  further  than  three  feet  and      with     metal 

11  1  mountings. 

then  fall  to  the  ground,  where  they 

are    less    likely    to  do  harm  than  when  directly 

coughed  into  a  person's  face  or  on  to  one's  cloth- 


INFECTION  BY  INHALATION 


II 


ing.     The  patient  should    remember   ahvays    to 

hold  his  hand  or  handkerchief  before  his  mouth 

when  coughing. 

The  physician  treating  the  patient  will,  of 
course,  prescribe  for  the  cough 
when  necessary;  but  he  will  also 
tell  the  invalid  that  he  must  con- 
trol useless  coughing;  in  other 
words,  he  should  never  cough  un- 
less he  feels  that  he  has  to  expec- 

FiG    lo      Kny-  toratc.     The    patient    should    un- 

Scheerer  Sanitas    dcrstand     that     tO      COUgh     without 

cup    or  poc-et  gxpectoratinsj  is  yielding  to  an  ir- 

use  made  of  tm      ^  ■•■    ^  o  j  o 

with  a  removable  ritatiou  of  the  throat  which  may  in 
pasteboard  con-  -j-jj^g  bccomc  a  habit  rather  than  a 

tainer.  .  .  .„ 

necessity.  A  strong  will  can  con- 
trol the  useless  cough,  or  the  cough  of  habit. 
If  the  patient  will  consider  it  as  impolite  to  cough 
uselessly,  particularly  in 
presence  of  others,  just  be- 
cause he  has  a  little  tickling 
in  the  throat,  as  it  is  impo- 
lite to  scratch  one's  head  in 
public  because  of  a  little 
itching,   he   will   be   greatly    fig.  n.    Johnson  &  john- 

helped    in    his   efforts.       The          ^^^'^    Pasteboard    Purse 
,  T  ,.,..,..  for  Sputum. 

other  thought  m  disciplining 

the  cough  should  be  that  useless  coughing  is  in- 


12 


TUBERCULOSIS 


Fig.    12. 


jurious  to  the   throat  and  invokes  an  unneces- 
sary expenditure  of  force. 

Besides  these  special  hygienic 
measures  which  the  patient  should 
carry  out,  there  is,  of  course,  also 
the  very  important  general  and 
personal  hygiene.  He  should  keep 
his  skin  in  good  condition  by 
Seabury  weekly  batlis  and  daily  sponges. 
'Jo  nsons.  e-  g^^^.^   ^^^    mustachc  should  not 

tallic    rrame    tor 

Pasteboard  Spu-  be  worn  at  all,  or  be  closely  cut. 

turn  Cup.  ^g     underwear     the    linen-mesh, 

heavy  weight  in  winter  and  light  weight  in  sum- 
mer, is  to  be  highly  recommended.  If,  as  happens 
in  some  cases,  the  patient  feels  cold  even  with  the 
heavy  weight  linen-mesh,  it  is  advisable  for  him 
to  wear  linen-mesh  next  to  the 
skin  and  an  additional  cotton, 
silk,  or  very  light  woolen  garment 
over  it.  Linen-mesh  underwear 
is  more  suitable  for  the  tuber- 
culous because  it  dries  quickly 
when  the  patient  perspires.  It 
produces  a  constant  pleasant  fric- 
tion on  the  skin,  and  is  prefer- 
able to  wool  or  cotton  in  that  the 
mesh  allows  a  better  ventilation  of  the  skin  and 
renders  the  patient  less  apt  to  catch  cold.    The  out- 


FiG.  13.  Pasteboard 
Container  to  Sea- 
bury  &  Johnson's 
Cup. 


INFECTION  BY  INHALATION  13 

side  garments  should  be  comfortable  and  accord- 
ing to  the  season,  light  in  summer,  warm  in  winter; 
but  not  too  heavy  so  as  to  hin- 
der free  movement.  All  gar- 
ments restricting  free  thoracic 
or  abdominal  breathing  should 
be  done  away  with.  The  high 
collar  for  men   and  the  high,  ^^^^  ^^^    ^^^^^^  Spit- 

tight,   stiff,  or  boned    collar  for        cup  Made  of  Pressed 

women,   or    anything    else    con-        Pasteboard  with  Cover 
•^  °  and  Handle. 

stricting  the  neck  is  injurious; 
so  is  the  tightly  laced  corset  and  tight  belt. 
Ladies'  skirts  should  be  partially  suspended  from 
the  shoulders  and  the  steel  corset  should,  when- 
ever possible,  be  replaced  by  a  comfortable  waist. 
With  everything  relating  to  his  personal  hygiene, 
to  the  prevention  of  infection  of  others  and  rein- 
fection of  himself,  the  patient  should  be  familiar. 
But  he  should  also  know  that  if  he  is  careful  and 
obeys  the  few  necessary  rules,  people  need  not  be 
afraid  but  should  gladly  associate  with  him.  He, 
himself,  because  of  his  knowledge  and  the  con- 
sciousness of  doing  his  duty,  will  be  happier  and 
freer  in  mind.  He  can  demonstrate  that  al- 
though tuberculosis  is  a  communicable  disease,  it 
is  by  no  means  to  be  classed  with  the  highly  con- 
tagious diseases  (the  word  "contagion"  comes 
from  the  Latin  contingere,  to  touch),  such  as  small- 


14  TUBERCULOSIS 

pox  for  example.  The  touch  of  the  clean,  con- 
scientious consumptive  can  not  give  tuberculosis. 

Another  fact  which  should  tend  to  cheer  the 
tuberculous  patient,  is  that  of  all  the  chronic 
diseases  his  is  curable  the  most  frequently.  It  is 
not  only  true  that  as  many  as  80  per  cent  of  cures 
are  reported  when  the  patient's  disease  was  dis- 
covered in  time  and  properly  treated,  but  the 
post-mortem  examinations  of  hundreds  and  hun- 
dreds of  cases  which  died  from  accident  or  other 
diseases  than  consumption  have  shown  the  scars 
of  a  healed  tuberculosis.  It  must  be  assumed 
that  in  these  cases  they  had  had,  at  one  time  or 
another,  a  little  tuberculosis  and  that  they  recov- 
ered perhaps  without  ever  having  known  that  they 
had  the  disease.  All  this  should  be  ample  proof 
of  the  curability  of  tuberculosis,  and  the  consump- 
tive should  be  hopeful  and  cheerful.  If  he  is  in 
the  earlier  stages  of  the  disease  and  submits  him- 
self to  proper  and  timely  treatment,  he  may  be 
reasonably  certain  of  an  absolute  recovery.  If  he 
has  passed  the  earlier  stages,  he  may  still  be  much 
improved  and  live  a  long  time  in  comfort  with 
his  earning  capacity  reestablished. 

However,  the  one  most  important  thing  the 
tuberculous  patient  should  know  of  his  disease  is 
that  unless  he  follows  the  instructions  of  his 
physician  to  the  letter  and  has  implicit  confidence 


GENERAL  PERSONAL  HYGIENE  15 

and  trust  in  him,  it  will  be  difficult  to  accomplish 
a  cure. 

In  no  disease  is  it  so  essential  to  attend  to 
minor  details  in  the  matter  of  sleeping  quarters, 
of  dress,  use  of  bath  (cold  or  warm),  exercise  and 
rest,  food,  and  medicine,  as  in  tuberculosis.  The 
implicit  obedience  to  the  physician's  orders,  the 
performance  with  religious  punctuality  of  all  the 
hygienic,  dietetic,  and  other  directions,  are  essen- 
tial and  important  for  a  patient  in  no  matter  what 
stage  of  the  disease.  It  can  not  be  emphasized 
too  much  that  the  medical  guidance  and  super- 
vision are  of  paramount  importance  to  the  patient 
whether  he  is  in  his  own  home,  in  a  health  resort, 
or  in  a  sanatorium,  and  no  matter  in  what  climate 
he  may  live.  The  patient  should  not  be  sensitive 
about  any  of  the  precautions  necessary  to  prevent 
the  spread  of  the  disease,  but  should  take  an 
interest  in  helping  those  about  him  carry  them  out 
to  the  most  minute  detail. 


CHAPTER  II 

"WBAT     THOSE     LIVING     WITH     PATIENTS     SHOULD 
KNOW   CONCERNING   THE   DISEASE 

Those  living  with  the  tuberculous  patient  should 
know  first  all  that  the  patient  ought  to  know,  that 
is  to  say,  what  has  been  outlined  in  the  preced- 
ing chapter;  but  it  will  also  be  their  duty  to  insist 
with  kindness  but  firmness,  as  long  as  the  patient 
is  able  to  do  so,  on  his  carrying  out  absolutely  the 
precautions  necessary  to  limit  the  danger  of  in- 
fection to  the  smallest  possible  degree.  If  he  is 
not  able,  they  must  do  it  for  him.  Indulgence  is 
out  of  place  in  tuberculosis.  It  should  be  im- 
pressed again  and  again  upon  the  heedless  patient 
that  his  carelessness  not  only  means  danger  to 
others  but  also  danger  to  himself  by  the  possibility 
of  reinfection.  It  should  be  explained  to  him 
that  the  inhalation  of  the  bacilli  which  he  has 
rejected  is  as  dangerous  to  him  as  to  others. 

When  the  patient  is  in  the  latter  stages  of  the 

disease  and  so  helpless  that  he  can  not  always 

make  use  even  of  a  light  pasteboard  (Fig.  14)  or 

aluminum  hand  spittoon,  he  should  be  provided 

16 


NATURAL  SOURCES  OF  DEFENSE  17 

with  moist  cloths,  kept  within  easy  reach,  into 
which  he  should  expectorate.  These  cloths  should 
in  turn,  while  still  moist,  be  wrapped  up  in  paper 
and  then  burned.  They  should  be  handled  as 
little  as  possible  if  the  tuberculous  sputum  upon 
them  should  have  become  dry. 

When  the  patient  and  those  living  with  him  do 
their  duty,  there  is  no  danger  of  contracting  the 
disease;  in  fact,  for  the  strong  and  well  the 
occasional  inhalation  of  a  few  bacilli,  the  occa- 
sional ingestion  of  tuberculous  meat  or  milk  is, 
after  all,  not  so  dangerous.  There  exist  powerful 
means  of  natural  defense  against  tuberculosis  in 
the  healthy  human  being.  The  tubercle  bacilh 
which  may  be  inhaled  are  taken  in  with  the  dust. 
This  dust  is  arrested  by  countless  fine  hairs  in  the 
nasal  cavities  and  during  the  act  of  blowing  the 
nose  this  bacilli-laden  dust  is  usually  expelled 
with  some  of  the  nasal  mucus.  When,  as  it  may 
happen,  some  bacilli  are  not  caught  up  by  the  fine 
hairs,  the  very  secretions  of  the  nasal  membranes 
being  bactericidal,  that  is  to  say,  having  germ- 
killing  properties,  can  render  the  bacilli  harm- 
less. Even  if  the  germs  should  have  passed  these 
two  barriers  and  have  entered  the  deeper  respir- 
atory tracts — the  bronchial  tubes — these  in  turn 
are  lined  with  cilia,  very  fine  hair-like  organs 
which  are   in  constant  motion,  and  which  expel 


i8  TUBERCULOSIS 

foreign  bodies  with  the  mucus  that  the  bronchial 
tubes  secrete.  Lastly,  even  should  the  bacilli  enter 
the  lung  tissue  itself,  there  again  they  will  meet 
the  white  blood  corpuscles,  and  if  the  latter  are 
plentiful  and  in  good  condition  they  will  over- 
come the  enemy — the  bacilli — by  swallowing  them. 
The  great  French  scientist,  Metchnikoff,  called  this 
method  of  natural  defense  of  the  blood  "phagocy- 
tosis," from  Greek  words  meaning  a  cell  which 
eats,  indicating  thereby  that  the  white  blood  cor- 
puscles devour  the  bacilli. 

One  thing  that  is  important  for  those  who  are 
living  with  the  tuberculous  to  know  is  that  while 
it  is  a  rare  occurrence  for  a  child  to  come  into  the 
world  with  a  tuberculous  lesion,  the  child  of  a  tuber- 
culous father  or  mother  very  often  inherits  a  certain 
physiological  poverty  which  is  called  a  predis- 
position. In  other  words,  while  all  the  organs  may 
be  perfectly  normal,  the  child  brings  with  it  as 
an  inheritance  from  a  sick  parent,  a  weak  consti- 
tution with  little  resisting  power  to  tuberculosis 
and  other  diseases.  When  now  the  offspring  of 
tuberculous  parents  is,  in  addition  to  its  weakened 
condition,  exposed  to  the  infection  of  tuberculosis, 
its  chances  to  contract  the  disease  are  certainly 
very  great. 

A  child  should  never  be  put  to  the  breast  of  a 
tuberculous   mother.      Not   only   may   the   child 


STERILIZATION  AND  PASTEURIZATION    19 

become  infected  by  the  milk,  but  to  nurse  it  is 
also  too  great  a  drain  on  the  mother's  constitution. 
While  the  woman  during  her  pregnancy  may  seem 
very  much  better,  unfortunately  her  condition  after 
childbirth  is  usually  worse,  and  it  would  be  most 
unwise  to  have  her  nurse  her  child  even  were  there 
no  danger  of  direct  infection  from  the  mother's 
milk.  Such  a  child  should  have  a  healthy  wet  nurse 
or  be  fed  artificially  with  the  best  and  purest  milk 
obtainable.  If  there  is  any  doubt  as  to  the  purity 
of  the  milk,  pasteurization  or  steriHzation  should 
be  resorted  to. 

Sterilization  is  usually  accomplished  by  keeping 
the  milk  at  the  boiHng  point  (212°  F.)  for  half  an 
hour. 

Pasteurization  is  the  process  of  heating  the  milk 
to  a  temperature  between  140^  and  176°  F.  for 
fifteen  or  twenty  minutes.  This  is  sufficient  to 
destroy  the  tubercle  bacilli  and  most  of  the  ordinary 
milk  germs  without  cooking  the  milk,  which  is 
generally  considered  to  render  it  less  nutritive 
and  digestible.  Even  pasteurization  deteriorates 
the  milk,  therefore  every  effort  should  be  made  to 
obtain  it  pure  and  fresh.  Whether  the  milk  comes 
directly  from  the  healthy  cow,  or  is  pasteurized  or 
sterilized,  it  should  be  cooled  quickly  and  kept 
cold  and  covered  until  it  is  to  be  used. 

The  closer  the  contact  in  which  the  tuberculous 


20  TUBERCULOSIS 

mother  and  child  Hve,  the  greater  is  the  danger  of 
infection.  If  the  mother  kisses  the  child  on  the 
mouth  or  puts  the  nipple  of  the  milk  bottle  or  the 
spoon  with  which  it  is  fed  into  her  own  mouth  to 
taste  the  milk  in  order  to  judge  of  its  temperature 
or  sweetness  before  giving  it  to  the  child,  it  is 
evident  that  infection  can  take  place  very  readily. 
If  the  mother  coughs  when  carrying  the  child  in 
her  arms,  the  little  drops  expelled  during  the 
cough  may  reach  the  child's  mouth  or  it  may 
inhale  these  bacilliferous  droplets.  If  the  tuber- 
culous mother  or  those  living  with  her  will  see  that 
the  simple  necessary  precautions  to  avoid  these 
postnatal  infections  (infection  after  the  child's 
birth),  are  carried  out,  there  will  be  an  excellent 
chance  for  the  child  to  grow  up  without  becoming 
infected.  Such  a  child  should  also  be  treated  for 
its  inherited  predisposition,  that  is  to  say,  it  should 
have  plenty  of  fresh  air,  proper  hygiene,  and  care 
in  general;  in  fact,  all  hygienic  measures  tending 
to  make  it  strong  and  resistant  to  disease  should 
be  inaugurated  at  the  earliest  possible  moment. 

For  the  further  protection  of  those  living  with 
the  patient  we  would  strongly  advise  that  the 
soiled  personal  and  bed  linen,  sheets,  pillow-cases, 
underwear,  napkins,  handkerchiefs,  etc.,  of  a 
consumptive  be  handled  as  little  as  possible  when 
dry.    Immediately  after  removal  from  bed  or  body 


CARE  OF  PERSONAL  AND  BED  LINEN      21 

the  soiled  linen  should  be  placed  in  water  and  be 
washed  separately  or  boiled  before  being  put  in 
with  the  general  laundry.  Cleaning  the  room 
should  never  be  done  w^ith  a  feather  duster  or 
broom.  If,  on  account  of  a  fixed  carpet,  sweeping 
is  inevitable,  let  it  be  preceded  by  throwing  moist 
sawdust  or  moistened  bits  of  paper  on  the  floor 
to  allay  the  dust.  It  is  well  also  while  sweeping  to 
lower  the  windows  from  the  top  and  keep  them 
closed  at  the  bottom.  The  woodwork  and  furni- 
ture should  be  wiped  with  a  moist  or  slightly  oily 
cloth  according  to  the  nature  of  the  surface. 
Whenever  possible,  the  cleaning  should  be  done 
by  the  pneumatic  exhaustive  or  vacuum  process. 
This  is  the  ideal  method  of  cleaning  the  apartment 
of  the  sick.  There  are  portable  devices  now  in  the 
market  which  can  be  procured  at  reasonable  rates 
and  thus  the  consumptive  poor  may  be  able  to 
avail  themselves  of  this  hygienic  mode  of  removing 
dust. 

It  is  necessary  to  remember  that  when  table 
utensils,  such  as  drinking  cups  and  glasses,  forks, 
spoons,  etc.,  which  come  in  direct  contact  with 
the  mouth,  have  been  used  by  a  consumptive, 
they  should  never  be  used  by  any  other  person 
before  they  have  been  thoroughly  washed  with  soap 
and  hot  water  or  placed  in  boiling  water  for  a  few 
moments.    No  one  else,  of  course,  should  use  the 


22  TUBERCULOSIS 

patient's  napkin.  If  he  cannot  have  a  clean  one 
at  every  meal,  it  is  well  to  keep  it  in  some  sort  of  an 
impermeable  case,  or  even  a  cover  of  washable  ma- 
terial so  that  it  need  not  be  handled  unnecessarily. 

With  the  training  which  teaches  the  invalid  when 
and  when  not  to  cough,  of  which  we  spoke  when 
discussing  w^hat  the  patient  should  know  of  his 
disease,  a  tuberculous  invalid  can  be  a  very  agree- 
able companion  at  the  table.  To  ask  an  honest, 
conscientious,  and  well- trained  consumptive  to  take 
his  meal  separately  is  as  unkind  and  unnecessary 
as  can  possibly  be,  and  certainly,  if  insisted  upon, 
it  is  enough  to  make  the  consumptive  patient  thor- 
oughly unhappy. 

It  should  be  the  privilege  of  those  living  with 
the  tuberculous  patient  to  make  him  as  happy,  as 
cheerful,  and  as  hopeful  as  possible.  Happy  sur- 
roundings, a  cheerful  face,  a  hopeful  word  for  the 
invalid  from  those  about  him  will  be  no  little 
factor  in  accomplishing  his  cure. 

Phthisiophobia,  that  is  to  say,  the  exaggerated 
fear  of  contracting  phthisis  or  consumption,  is 
entirely  out  of  place  when  the  patient  is  con- 
scientious and  careful.  It  is  not  only  out  of  place, 
})ut  it  is  cruel.  Some  people  in  their  fear  and 
prejudice  go  so  far  as  not  only  to  consider  the 
consumptive  a  physical  danger  but  also  as  men- 
tally peculiar  or  something  worse.    Phthisiophobia 


EXAGGERATED  FEARS  23 

resembles  an  epidemic  disease  which  now  and 
then  crops  up  in  different  locahties.  That  there 
is  no  danger  from  the  clean  conscientious  con- 
sumptive has  often  been  sufficiently  demonstrated, 
and  to  think  him  differently  constituted  mentally 
from  well  persons  or  people  affficted  with  other 
physical  ailments  is  quite  absurd. 

Not  so  very  long  ago  a  young  physician  startled 
the  medical  and  lay  press  by  making  the  statement 
that  the  average  consumptive  is  afflicted  with 
mental  and  moral  aberration.  He  made  the  to- 
tally unwarranted  assertion  that  in  the  typical 
consumptive  psychasthenia,  the  loss  of  self-control 
and  the  rise  of  brute  selfishness  combine  to  distort 
the  clearness  of  his  ethical  perception.  I  replied 
to  this  statement  at  the  time  in  an  address  before 
the  Society  of  Medical  Jurisprudence,  entitled 
'^A  Plea  for  Justice  to  the  Consumptive."  To 
strengthen  the  force  of  my  own  experience,  I  had 
collected  the  opinions  of  twelve  of  the  leading 
authorities  of  this  country  on  tuberculosis  and 
mental  diseases,  and  all  of  them  agreed  with  me  on 
the  injustice  of  making  the  statement  above  re- 
ferred to. 

It  would  take  too  much  space  here  to  give  all  the 
valuable  letters  and  expressions  of  opinion  received 
at  the  time  from  such  men  as  Professors  Hermann 
M.  Biggs  of  New  York,  S.  G.  Bonney  of  Denver, 


24  TUBERCULOSIS 

Mncent  Y.  Bowditch  of  Boston,  E.  D.  Fisher  of 
New  York,  A.  Jacobi  of  New  York,  Edward  G. 
Janeway  of  New  York,  Arnold  C.  Klebs  of  Chi- 
cago, Wilham  Osier  of  Oxford,  England,  Edward 
O.  Otis  of  Boston,  E.  L.  Trudeau  of  Saranac 
Lake,  James  Tyson  of  Philadelphia,  and  Dr.  J. 
B.  Ransom,  Prison  Physician  of  Elmira,  N.  Y.  I 
will,  however,  reproduce  the  opinions  of  three  men 
who  may  justly  be  said  to  be  leaders  in  the  sci- 
entific medicine  of  the  English-speaking  world. 
Professor  Edward  G.  Janeway,  Dean  of  the  Med- 
ical Faculty  of  Bellevue  and  New  York  Univer- 
sity, wrote  me:  ''I  have  not  noticed  any  such 
tendency  as  you  inquire  about  on  the  part  of 
consumptives  as  regards  immorality  or  crime  as 
compared  with  well  people  or  with  those  ill  with 
other  diseases,  placed  under  similar  circumstances. 
It  is  to  be  remembered  that  criminals  and  the 
insane  are  prone  to  be  victims  of  tuberculosis, 
and  hence  someone  who  studied  this  class  of 
people  would  be  liable  to  form  very  unjust  views 
about  the  consumptive  class  as  a  whole.  Nor  is  it 
my  experience  that  the  average  consumptive  is 
inclined  to  brute  selfishness,  loss  of  self-control, 
and  hence  distortion  of  the  clearness  of  ethical 
perception.  I  have  found  so  much  to  the  contrary 
that  I  am  surprised  at  so  broad  a  charge  against 
the  consumptive  invalid," 


TUBERCULOSIS  INVALIDS  25 

Dr.  William  Osier,  Regius  Professor  of  Medicine 
of  Oxford,  England,  wrote:  "I  quite  sympathize 
with  you  in  your  movement,  and  in  reply  to  your 
question  I  would  say,  first,  I  have  never  noticed 
among  consumptives  any  greater  tendency  to  im- 
morality or  crime  than  in  other  individuals;  I 
should  rather  say  the  contrary.  IMy  impression  is 
that  the  unfortunate  victims  of  tuberculosis  are 
above  the  average  in  their  mental  and  moral  char- 
acter; secondly,  I  should  say  emphatically  that  the 
average  consumptive  is  neither  inclined  to  brute 
selfishness  nor  any  special  distortion  of  the  ethical 
perceptions.  I  am  glad  you  called  my  attention  to 
the  article  in  the  '  New  York  Medical  Journal.' 
So  far  as  my  experience  goes,  such  statements  as 
you  say  are  made  therein  are  an  unwarranted 
slander." 

The  last  letter  comes  from  a  man  to  whom  all 
who  know  him  personally,  or  know  his  works, 
look  up,  not  only  as  a  great  physician,  scientist, 
and  specialist  on  tuberculosis  and  the  pioneer  of 
the  sanatorium  treatment  in  this  country,  but  also 
as  a  great  humanitarian  and  a  most  noble  char- 
acter. He  is  an  example  of  what  a  man,  though 
consumptive  himself,  can  do  for  his  fellow-men. 
Dr.  Edward  L.  Trudeau,  who  twenty-five  years 
ago  as  a  seemingly  hopeless  invalid,  made  his  home 
in  the  wilderness  of  the  iVdirondack  Mountains, 


26  TUBERCULOSIS 

became  through  his  untiring  work,  his  unselfish  de- 
votion to  science  and  the  highest  ideals  of  human 
helpfulness,  the  founder  of  one  of  the  most  beau- 
tiful and  flourishing  sanatoria  for  the  consumptive 
poor  in  the  world,  the  founder  of  a  prosperous 
village  crowded  with  consumptives  of  the  wealthier 
classes,  a  teacher  to  the  medical  profession  of 
practical  phthisiotherapeutics,  and  a  teacher  of 
practical  philanthropy  to  the  American  public 
and  the  world  at  large.    These  are  his  words: 

^'I  have  never  noticed  any  greater  tendency  to 
immorality  or  crime  among  consumptives  than 
is  to  be  found  in  the  average  of  the  human  race, 
as  far  as  it  has  come  under  my  observation.  On 
the  contrary,  I  have  seen  all  the  finer  traits  of 
human  nature  developed  to  the  fullest  extent  by 
the  burdens  which  chronic  and  fatal  illness,  often 
slow  in  its  progress,  adds  to  the  sum  total  of  what 
men  and  women  usually  have  to  endure  in  life. 
I  have  seen  certainly  more  patience,  courage, 
self-denial,  and  unselfish  devotion  to  others  in 
consumptives  than  I  have  noticed  in  the  majority  of 
healthy  human  beings.  Indeed,  the  sanatorium 
work  never  could  have  been  carried  on  were  it  not 
for  the  self-sacrificing  devotion  to  the  suffering 
of  others  shown  by  my  associates,  the  nurses,  and 
even  the  employees  at  the  sanatorium,  most  of 
them  having  come  here  originally  because  suffer- 


TUBERCULOSIS  INVALIDS  27 

ing  from  tuberculous  disease.  History  is  full  of 
instances  which  prove  that  tuberculosis  does  not 
interfere  with  the  development  to  the  highest 
degree  of  the  intellectual,  the  moral,  or  the  ethical 
sides  of  man's  nature." 

It  would  hardly  seem  necessary  after  quoting 
the  opinions  of  these  three  distinguished  au- 
thorities to  add  my  own  opinion,  though  based 
upon  an  experience  of  many  years  of  practice 
among  consumptives  in  different  climes  and  dif- 
ferent countries,  among  men  and  women  in  all 
stations  of  life.  I  may  say  that  I  have  not  only 
practiced  but  also  lived  among  them  and  with 
them,  and  from  all  my  experience  I  can  only 
confirm  what  has  been  said  by  the  three  great 
physicians  just  mentioned.  Never  have  I  noticed 
consumptives  to  be  more  inclined  to  immorality 
than  individuals  afflicted  with  other  diseases,  or 
even  well  people;  only  in  a  few  instances  have  I 
noticed  real  selfishness,  and  never  what  one  could 
call  a  distortion  of  the  clearness  of  ethical  percep- 
tion, among  them.  On  the  contrary,  as  in  the  expe- 
rience of  Drs.  Osier,  Janeway,  and  Trudeau,  it  has 
always  seemed  to  me  that  many  consumptives  are 
above  the  average  in  their  mental  and  moral  char- 
acteristics. Instead  of  selfishness,  I  have  fre- 
quently witnessed  the  most  touching  evidence  of 
self-sacrifice  and  devotion.    I  have  seen  colleagues 


2S  TUBERCULOSIS 

in  institutional  and  private  practice,  trained  nurses 
and  sisters  of  charity,  who,  though  they  knew 
they  had  contracted  tuberculosis  in  the  pursuit 
of  their  professional  duties,  did  not  leave  the 
battlefield,  but  continued  to  labor  and  help  their 
consumptive  fellow-sufferers.  Two  of  my  most 
beloved  teachers,  to  whom  I  owe  an  everlasting 
debt  of  gratitude  for  the  inspiration  and  help  they 
have  given  me  in  my  work.  Professor  Grancher 
of  Paris  and  Geheimrath  Dettweiler  of  Falken- 
stein,  were  both  consumptive.  They  taught  and 
practiced  among  consumptives  for  a  quarter 
of  a  century,  and  remained  leaders  in  the  anti- 
tuberculosis crusade  until  the  end  of  their  most 
useful  lives. 


CHAPTER  III 

THE  DUTIES  OF  THE  PHYSICIAN  TOWARDS  HIS 
PATIENT,  THE  FAMILY  OF  THE  PATIENT,  THE 
COMMUNITY  HE  LIVES  IN,  AND  OTHER  COM- 
MUNITIES 

The  duties  of  the  family  physician  in  regard  to 
the  tuberculosis  problem  are  manifold.  We  will 
begin  by  the  discussion  of  his  duty  towards  the 
patient.  The  first  question  to  arise,  if  the  care- 
ful examination  of  an  intelligent  patient  has  shown 
him  to  be  tuberculous,  is,  should  the  physician  tell 
or  not  tell  this  fact  to  the  patient  ?  I  believe  it  to 
be  his  sacred  duty  to  inform  an  adult  patient  of 
the  true  character  of  the  disease  and  also  to  in- 
form the  family  of  the  situation.  To  hide  from  the 
intelligent  adult  the  fact  that  he  is  tuberculous  or 
that  a  member  of  his  family  is  afflicted  with  the 
disease,  is,  in  the  light  of  our  modern  knowledge, 
an  absolute  wrong;  or  it  may  even  be  called  a 
criminal  neglect.  That  the  family  physician  will 
use  the  utmost  tact  in  revealing  such  a  condition 
to  the  patient  or  to  the  friends  of  the  patient  is 

a  matter  self -understood.     What  we  know  to-day 

29 


30  TUBERCULOSIS 

of  the  curability  of  an  early  tuberculosis  makes 
the  task  all  the  more  easy.  One  can  inspire  the 
patient  and  his  friends  with  the  hope  of  absolute 
recovery  when  in  the  presence  of  an  early  tuber- 
culosis. 

In  order  to  overcome  the  shock  which  the  reve- 
lation of  the  presence  of  the  disease  at  times 
causes  the  patient,  it  has  been  my  practice  to  say 
to  him,  "Be  grateful  for  this  early  discovery  of  a 
curable  condition,  which,  when  overcome,  may 
leave  you  a  stronger  and  more  vigorous  man  than 
you  ever  were  before." 

After  having  inspired  the  patient  with  hope  and 
gained  his  complete  confidence,  the  next  duty  of 
the  physician  is  naturally  to  tell  the  patient  what 
he  should  know  of  his  disease;  in  other  words,  to 
impart  to  him  such  knowledge  and  information 
as  it  has  been  our  endeavor  to  give  in  the  first 
chapter. 

While  it  is  desirable  that  the  physician  should 
have  leaflets  of  instructions  ready  to  hand  to  the 
patient  for  careful  perusal,  the  spoken  word,  the 
verbal  instruction  must  not  be  neglected.  What- 
ever literature  the  physician  may  give  to  his 
patient,  it  should  always  be  supplemented  by  a 
few  words  of  explanation. 

All  preventive  measures  intended  to  protect 
those  living  and  associating  with  a  consumptive 


INSTRUCTION  TO  THE  PATIENT  31 

from  infection  and  himself  from  reinfection,  should 
be  inaugurated  at  once.  It  is  sometimes  difficult 
to  make  the  necessary  installation  for  the  home 
treatment.  It  is  not  wise  nor  judicious  to  put  a 
family  of  moderate  means  to  the  expense  of  build- 
ing porches  for  outdoor  sleeping,  of  changing  domi- 
cile, of  buying  window- tents,  reclining  chairs  and 
other  paraphernalia  when  it  is  in  the  interest  of 
the  patient  and  of  his  family  that  he  should  be 
sent  to  a  sanatorium,  hospital,  or  health  resort. 

Whether  it  is  best  for  the  patient  to  go  to  an 
institution,  sanatorium,  or  hospital,  to  make  a  cli- 
matic change  or  to  remain  at  home,  will  depend 
upon  the  financial  and  other  circumstances  of  the 
family,  upon  the  patient's  character,  his  peculiari- 
ties and  above  all,  upon  his  condition.  A  com- 
petent physician  will  know  when  a  change  of 
climate  is  desirable,  feasible,  or  immaterial.  He 
will  bear  in  mind  the  patient's  peculiarities  and 
recall  that  patients  much  attached  to  home  life 
are  apt  to  suffer  from  nostalgia  (homesickness) 
when  sent  away,  and  because  of  depression  and 
lonehness  do  badly  under  those  circumstances. 
The  homesick  patient  eats  little  and  in  his  de- 
spondent moods  is  very  apt  to  forget  to  follow  the 
directions  about  outdoor  life,  breathing,  walking, 
careful  exercise,  etc.,  so  essential  to  his  well-being. 
On  account  of  this  peculiarity,  some  patients  do 


32  TUBERCULOSIS 

better  at  home  even  in  a  less  congenial  climate, 
because  they  are  happy  and  contented  there  and 
willing  to  obey  all  the  necessary  hygienic  and 
dietetic  directions.  The  physician  will  also  recog- 
nize the  class  of  patients  who  must  go  away  and 
should  be  in  some  special  institution  because  at 
home  they  will  not  obey  the  instructions  so  es- 
sential to  increase  their  chances  of  recovery.  Some 
patients  for  w^hom  a  climatic  change  is  desirable 
may  do  well  in  a  health  resort  under  the  guidance 
of  a  physician. 

If  the  patient  is  to  remain  at  home,  it  is,  of 
course,  presumed  that  the  home  is  so  situated 
that  all  the  preventive  and  curative  measures  es- 
sential to  the  treatment  can  be  carried  out.  Since 
experience  has  shown  that  the  sanatorium  method 
of  healing  tuberculous  patients  is  the  best,  we 
will  in  the  following  chapter  describe  how  this 
treatment  may  be  adapted  to  and  imitated  in  the 
homes  of  the  well-to-do  or  the  poor.  There  are, 
of  course,  instances  when  the  physician  may  be 
in  the  presence  of  an  advanced  case  for  which  a 
change  of  climate  may  be  useless,  and  for  people 
in  moderate  circumstances  the  sacrifice  of  sending 
a  patient  away  may  mean  a  good  deal.  This  the 
conscientious  physician  will  take  into  considera^ 
tion. 

If  it  is  ];x:)ssiblc  for  a  family  in  which  tubercu 


MAXIMS  IN  CHOICE  OF  CLIMATE  33 

losis  has  appeared  to  leave  the  large  overcrowded 
city  for  a  healthful  country  district,  or  even  less 
congested  portions  of  the  city,  where  they  will  be 
able  to  support  themselves  just  as  well  and  have 
in  addition  greater  comfort,  purer  air,  and  more 
outdoor  life,  it  is  the  physician's  duty  to  urge  such 
a  change. 

Not  all  physicians  can  be  expected  to  be  thor- 
oughly familiar  with  the  climatic  conditions  of 
the  various  parts  of  the  country,  therefore  the 
following  maxims  for  the  selection  of  climate  in 
pulmonary,  laryngeal,  and  bone  tuberculosis  may 
be  helpful.  These  maxims  I  presented  at  the 
occasion  of  a  discussion  on  climate  in  the  treat- 
ment of  tuberculosis  before  the  Clinical  and 
Clim.atological  Section  of  the  National  Association 
for  the  Study  and  Prevention  of  Tuberculosis,  at 
the  second  annual  meeting  in  Washington,  May 
18,  1906.  They  are  the  result  of  long  experience, 
and  have  guided  me  in  years  of  practice  among 
the  tuberculous  whenever  I  was  called  upon 
to  decide  or  advise  on  a  climatic  change  for  a 
patient. 

(i)  To  deny  the  beneficial  influence  of  certain 
climatic  regions  as  a  valuable  adjuvant  in  the 
treatment  of  tuberculosis  is  as  dangerous  and  un- 
scientific as  the  belief  in  the  specific  curative 
quahty  of  any  particular  climate. 


34  TUBERCULOSIS 

(2)  A  change  of  climate,  though  not  necessarily 
a  marked  one,  except  in  the  very  latter  stages  of 
the  disease  if  of  either  a  pulmonary  or  laryngeal 
character,  is  nearly  always  good.  While  a  change 
from  an  unfavorable  climate  to  a  favorable  one, 
or  from  a  good  to  a  better,  must  naturally  be  con- 
sidered preferable,  this  rule  is  by  no  means  in- 
flexible. When  the  patient  has  contracted  tubercu- 
losis in  a  favorable  climate,  a  change  to  another, 
even  to  a  seemingly  less  favorable  one,  may  ac- 
complish as  much  good  for  this  invalid  as  the 
reverse  in  others. 

(3)  The  native  locality  of  the  tuberculous  must 
be  taken  into  consideration  when  making  a  cli- 
matic change.  The  patient  who  spent  his  early 
youth  in  Norway  or  other  parts  of  northern  Europe, 
or  one  born  in  Massachusetts,  Maine,  or  northern 
New  York  where  the  winters  are  rigorous,  will 
usuallv  do  better  in  such  climates  as  Colorado, 
the  Adirondacks,  Sullivan  or  Orange  counties  of 
New  York  offer.  The  sons  and  daughters  of  sunny 
Italy  and  Americans  born  in  the  warmer  zones, 
will  do  better  in  climates  such  as  arc  to  be  found 
in  southern  California,  New  Mexico,  Arizona, 
North  and  South  Carolina,  Virginia,  Florida,  Ber- 
muda, etc. 

(/\)  To  the  foregoing  rule  there  are  exceptions, 
and  besides  considerations  of  nativity  one  should 


CHOICE  OF  CLIMATE  35 

be  guided  in  a  large  measure  by  the  patient's 
personal  experience.  For  example,  a  cold  climate 
may  be  selected  if  the  patient  has  found  that  he 
feels  more  comfortable  and  less  distressed  in  win- 
ter. A  change  to  a  warmer  climate  is  indicated 
when  the  reverse  is  the  case.  When  the  experience 
of  the  patient  has  demonstrated  that  he  felt  better 
when  near  the  seacoast,  or  vice  versa,  this  factor 
must  also  serve  as  an  indication  for  his  domicile 
while  seeking  cure. 

(5)  There  exist  idiosyncrasies  in  regard  to 
climatotherapeutics  and  aerotherapeutics  (a  pecul- 
iar constitutional  disposition  or  susceptibility)  as 
there  exist  in  hydrotherapeutics,  electrotherapeu- 
tics, and  medicinal  therapeutics.  These  idiosyn- 
crasies cannot  be  discovered  beforehand,  they 
can  only  be  learned  by  experience. 

(6)  High  (above  3,000  feet),  moderately  high 
(1,500  to  3,000  feet),  and  low  altitudes,  hot  and 
cold  regions,  seacoast,  and  ocean  climates,  pro- 
longed voyages,  and  life  on  house  boats,  on  rivers 
and  lakes,  extreme  dryness  and  moisture  have  all 
proved  advantageous  conditions  in  numbers  of 
cases. 

(7)  The  value  of  any  climate  to  a  tuberculous 
patient  can  not  be  determined  by  or  compared 
with  any  other,  unless  the  patient  lives  under 
careful    medical    guidance    in    a    sanatorium    or 


36  TUBERCULOSIS 

private  home,  and  follows  the  best  hygienic  and 
dietetic  treatment. 

(8)  Laryngeal  cases  (tuberculosis  of  throat),  in 
the  earlier  stages  with  relatively  little  pulmonary 
involvement,  are  often  benefited  by  a  change  to  a 
moderately  high  or  to  a  warm  moist  climate  with 
between  500  and  1,500  feet  of  altitude,  particu- 
larly when  there  is  a  chronic  feeling  of  dryness  in 
the  throat.  When  there  is  a  tendency  to  moist 
catarrh,  even  very  dry  and  hot  climates,  provided 
dust  storms  are  not  frequent,  are  often  beneficial. 
In  pulmonary  cases  a  weak  heart,  distinctive  heart 
or  kidney  lesions,  emphysema,  constant  fever,  and 
extreme  nervousness  are  contra-indications  to  high 
altitudes.  Whenever  such  pathological  conditions 
do  not  exist,  high  altitudes,  and  cold  or  cool,  or  hot 
and  dry  regions,  if  dust  free,  will  always  prove  a 
valuable  adjuvant  in  the  treatment  of  tubercu- 
losis. Early  pulmonary  hemorrhage  per  se  need 
not  be  considered  in  determining  a  choice  of 
climate.  However,  as  a  rule,  and  particularly 
in  cases  inclined  to  frequent  haemoptysis  (spitting 
of  blood),  long  journeys  should  Ijc  made  with 
frequent  rests  and  high  altitudes  approached 
gradually.  Not  a  few  cases  with  slight  bronchial 
symptoms  (bronchitis),  but  with  weak  hearts  and 
evidences  of  mixed  infection  do  well  at  the  seacoast 
for  the  greater  part  of  the  year.    Prolonged  ocean 


CHOICE  OF  CLIMATE  37 

voyages  may  also  prove  beneficial  in  such  cases. 
The  patient,  however,  must  not  be  subject  to  sea- 
sickness, must  be  fond  of  the  ocean,  and  be  in  a 
situation  to  travel  in  comfort  and  with  ease,  on  a 
steamer  or  large  ship  which  has  a  medical  ofhcer 
on  board. 

(9)  The  ideal  climate  for  the  average  pulmonary 
patient  in  the  earlier  and  more  hopeful  stages  of 
the  disease,  is  one  where  the  extremes  of  tempera- 
ture are  not  great,  with  a  pure  atmosphere,  rela- 
tively little  humidity,  much  sunshine,  and  all 
conditions  which  permit  the  patient  to  live  com- 
fortably out  of  doors  the  largest  number  of  days 
out  of  the  year,  and  the  largest  number  of  hours 
out  of  the  twenty-four.  For  tuberculosis  of  the 
bones  and  joints  and  scrofulous  affections  of  child- 
hood, the  seacoast  climates  in  our  temperate  zones 
come  nearer  to  deserving  the  term  specific  than 
anything  else.  The  peculiarly  beneficial  influence 
of  seacoast  climate  in  glandular,  bone,  and  joint 
tuberculosis  is  doubtlessly  to  be  ascribed  to  the 
aseptic  and  ozonic  quality  of  the  air,  and  the 
iodides  and  other  salts  suspended  therein.  But 
pure  air  and  outdoor  life,  in  whatever  locality, 
can  and  should  be  utilized  in  the  treatment  of 
tuberculosis  and  of  scrofulous  affections  of  chil- 
dren. Very  anaemic  pulmonary  cases  with  dry 
catarrhal  symptoms  of  the  upper  resDiratory  tract 


38  TUBERCULOSIS 

often  do  ^Yell  in  the  warmer  seacoast  climates. 
The  colder  seacoast  climates  are  perhaps  only 
suited  for  tuberculous  patients  when  they  are 
fairly  robust. 

(lo)  In  the  choice  of  locality  for  a  climatic 
change  for  any  patient,  besides  the  pathological 
considerations  enumerated  in  paragraph  8,  many 
factors  must  be  taken  into  account.    These  are: 

(a)  If  the  patient  wishes  to  return  to  his  former 
home  after  improvement  or  restoration  to  health, 
may  he  do  so  safely  or  not  ?  Experience  has  shown 
that  when  great  climatic  changes  have  been  made, 
patients  frequently  have  relapsed  on  returning  to 
their  former  home. 

(h)  If  the  patient  is  married  or  single,  young  or 
old,  willing  or  unwilling  to  leave;  if  the  patient  is 
subject  to  nostalgia,  and  generally  much  attached 
to  home  environments,  sending  him  far  away, 
particularly  if  against  his  wish,  may  produce 
disastrous  results,  for  mental  depression  aggra- 
vates pathological  conditions  and  retards  recovery. 

(c)  If  the  patient  is  sanguine  and  cheerful  he 
will  usually  do  well  even  at  long  distances  from 
home,  in  isolated  regions,  within  or  outside  of  a 
sanatorium. 

{(l)  For  the  morose  and  hypochondriac  patient, 
isolation  or  long  distances  away  from  home  have 
often  profluced  the  same  results  as  nostalgia. 


THE  PHYSICIAN'S  DUTY  39 

(e)  To  remove  an  advanced  and  evidently  hope- 
less case  from  his  home  to  a  long  distance  is  as 
cruel  as  it  is  unscientific,  unless  it  is  done  by  the 
patient's  special  request  and  with  the  likelihood 
of  lessening  his  sufferings  and  making  him  happier 
in  general.  Slight  climatic  changes  with  short 
distances  to  travel  are  often  beneficial  in  such  far 
advanced  cases  when  the  patient  is  perfectly 
willing  to  go. 

(/)  The  patient's  financial  condition  must  be 
such,  that  by  his  removal  to  distant  localities  and 
his  subjecting  himself  to  the  hygienic  and  dietetic 
treatment  in  special  institutions  or  health  resorts, 
he  will  not  become  destitute  and  a  burden  to  the 
community  which  has  extended  its  hospitality  to 
him.  His  means  should  be  sufficient  to  avoid  all 
possible  anxiety  and  worry  in  this  regard. 

(11)  When  the  situation  is  such  that  the  choice 
of  home  climate  or  home  treatment  must  be  taken 
into  consideration,  we  should  bear  in  mind  the 
following:  The  patient  will  do  better  in  the  out- 
skirts of  the  city  than  in  the  city  proper ;  better  in 
the  higher  parts  of  the  locality  than  in  the  lower; 
better  in  a  clear  or  relatively  clear,  dustless  at- 
mosphere than  in  a  dusty  one;  better  in  a  pure, 
smokeless  or  relatively  clear  and  smokeless  locality, 
than  in  one  full  of  smoke  and  odors;  better  in  a 
locality  where  he  may  get  the  benefit  of  whatever 


40  TUBERCULOSIS 

sunshine  there  is  than  in  a  valley,  canon,  or  narrow 
street  surrounded  by  high  buildings;  better  where 
there  are  few  houses  than  many;  better  where 
there  are  relatively  few  people  than  where  there  is 
overcrowding;  better  where  there  is  little  traffic 
and  little  noise  than  the  reverse. 

(12)  Lastly,  we  must  consider  that  the  majority 
of  consumptives  are  recruited  from  the  laboring 
classes  and  those  we  must  cure  in  the  same  or 
nearly  the  same  climate  in  which  they  will  have 
to  live  and  labor  after  their  restoration  to  health. 
While  the  cure  of  the  consumptive  individual  in 
his  home  climate,  which  is  in  most  instances  far 
from  the  ideal,  may  often  necessitate  a  longer 
space  of  time,  in  the  end  there  is  an  advantage  in 
this.  Experience  has  demonstrated  that  relapses 
among  this  class  of  patients  are  fewer,  and  the  cures 
more  assured  and  lasting  than  those  obtained  in 
more  congenial  climates. 

The  duties  of  the  physician  toward  the  family  of 
the  patient  are  as  important  as  those  to  the  patient. 
In  a  family  where  there  is  a  consumptive,  every 
member  should  be  examined  and  periodically 
reexamined  for  tuberculosis,  that  is  to  say,  their 
chests  should  be  gone  over  carefully  every  three 
to  six  months.  The  discovery  of  cases  of  tuber- 
culosis in  the  very  incipient  stages  will  naturally 
be  much  more  frequent  if  this  is  done  than  is 


THE  PHYSICIAN'S  DUTY  41 

usually  the  case.  As  is  well  known,  the  earlier  a 
case  of  tuberculosis  is  discovered  the  greater  are 
the  chances  for  cure,  if  timely  and  judicious  treat- 
ment is  given. 

For  the  practitioner  who  is  not  the  family  phy- 
sician, but  is  called  in  to  take  care  of  a  consump- 
tive patient,  it  is  naturally  a  delicate  task  to  seek 
to  examine  all  the  members  of  the  family.  Few 
physicians  can  afford  to  work  in  every  instance  for 
nothing  and  small  minds  may  interpret  the  honest 
desire  of  a  physician  to  do  his  duty  as  a  scheme 
to  make  money.  There  is  only  one  way  of  avoiding 
this  suspicion;  that  is,  for  the  physician  to  tell 
these  families  to  have  their  regular  family  phy- 
sician examine  them,  or  if  they  have  none,  to  call 
in  some  physician  they  may  have  consulted  be- 
fore, when  in  need  of  medical  advice. 

The  physician  treating  a  family  where  there  is 
a  consumptive  should  bear  in  mind  the  multiple 
sources  of  postnatal  infection  and  insist  upon  the 
carrying  out  of  the  precautions  to  prevent  them. 
He  should  see  that  an  inherited  predisposition  in 
any  one  of  the  members  is  overcome  by  the  proper 
care  that  should  be  bestowed  upon  them.  If  at  all 
possible,  predisposed  children  should  be  sent  to 
open  air  schools;  but  they  should  never  be  sent  to 
school  before  the  age  of  eight. 

The  physician  of  such  a  family  has  a  great 


42  TUBERCULOSIS 

responsibility  in  regard  to  the  lives  of  the  children. 
When  the  time  comes  for  them  to  choose  a  trade 
or  profession,  they  should  not  follow  occupations 
which  are  likely  to  increase  their  susceptibility 
to  tuberculosis.  They  should  be  prevented  from 
following  the  occupation  of  the  father  if  the  phy- 
sician has  cause  to  believe  that  the  employment 
in  which  a  consumptive  parent  had  been  engaged 
was  in  a  measure  responsible  for  the  development 
of  the  disease.  Thus,  for  example,  the  daughter 
of  a  consumptive  seamstress  should  not  also  be- 
come a  seamstress;  the  son  of  a  consumptive 
tailor,  hat  maker,  weaver,  stonecutter,  etc.,  should 
not  follow  the  same  confining  or  predisposing  oc- 
cupation. 

Young  men  or  women  with  hereditary  predis- 
positions to  tuberculosis,  should  seek  occupation 
which  will  assure  a  good  deal  of  open  air  exercise, 
without,  however,  exposing  them  to  great  physical 
strain  and  unusually  hard  work. 

When  the  physician  lives  in  a  community  where 
compulsory  or  even  only  voluntary  notification 
of  tuberculous  cases  is  required,  it  is  his  bounden 
duty  to  report  each  case.  He  will  thus  enable 
the  health  authorities  to  have  correct  statistics 
and  also  enable  them  to  trace  and  remove,  in 
many  instances,  underlying  causes  of  the  preva- 
lence of  tuberculosis  in  certain  localities,  districts, 


THE  PHYSICIAN'S  DUTY  43 

Or  even  houses.  The  health  authorities  of  any  city, 
even  if  the  notification  is  compulsory,  will  not 
interfere  with  the  physician's  patients  if  the 
former  assumes  the  responsibility  that  the  neces- 
sary precautions  to  prevent  tuberculous  infec- 
tion will  be  carried  out. 

The  physician,  besides  being  the  medical  ad- 
viser of  the  family,  is  also  a  citizen  and  may  at 
times  be  called  upon  for  medical  advice  by  the 
municipality  in  Avhich  he  lives.  In  his  double 
capacity  of  physician  and  citizen  he  is  particu- 
larly fitted  to  organize  and  help  the  popular 
crusade  against  tuberculosis.  In  communities 
where  there  are  no  anti-tuberculosis  committees 
or  associations,  the  progressive  physician  should 
see  that  they  are  started,  maintained,  and  do  the 
necessary  work.  He  should  be  helpful  to  combat 
tuberculosis  in  his  community  in  every  way  his 
time  and  means  allow. 

The  physician  treating  tuberculous  patients 
not  only  has  a  responsibility  toward  the  community 
in  which  he  lives,  but  also  one  toward  the  many 
communities  located  in  regions  reputed  for  cer- 
tain climatic  advantages.  Should  a  physician 
send  a  patient  in  the  curable  stage  of  a  tuber- 
culous disease,  who  has  little  or  no  means,  to 
a  far  away  climate  in  the  hope  that  in  a  few  weeks 
he  may  find  light  employment,  when  this  patient 


44  TUBERCULOSIS 

is  still  in  need  of  rest  and  care?  To  do  this  is 
an  injustice  to  the  community  to  which  the  patient 
is  sent.  Even  a  patient  in  the  very  early  stages 
of  the  disease  should  not  be  sent  to  such  a  distant 
climatic  resort,  unless  the  physician  is  pretty  cer- 
tain that  his  patient  will  be  able  to  work  in  a  few 
weeks  and  to  find  work  that  will  permit  him  to 
complete  his  cure.  Not  unless  such  a  patient  can 
with  reasonable  certainty  be  pronounced  curable 
should  he  be  sent  away,  and  not  without  being 
provided  with  funds  sufficient  to  last  him  at  least 
a  year. 

If  the  patient  is  well  to  do  and  the  physician 
knows  that  he  will  never  become  a  burden  to 
the  community,  it  is  his  right  and  duty  to  send 
him  to  any  climatic  resort  or  institution  where 
he  thinks  the  patient  will  do  well.  Even  in  the 
advanced  stages,  if  the  patient  has  a  desire  for  a 
change,  the  physician  may  yield  to  his  wishes  and 
allow  him  to  go  to  a  climate  where  he  thinks  he 
will  feel  more  comfortable.  The  invalid  should, 
of  course,  be  accompanied  by  a  trained  nurse  or 
attendant  so  that  he  will  not  be  a  source  of  danger 
to  any  one  on  the  trip  or  in  the  place  where  he  may 
become  permanently  located. 

If  a  patient  in  the  later,  or  even  the  earlier 
stages  of  the  pulmonary  tuberculosis  is  being 
treated  in  his  own  home  and  the  physician  finds 


DISINFECTION  OF  ROOMS  45 

that  a  disinfection  of  the  rooms  in  which  the 
patient  hves  is  desirable,  he  should  not  hesitate 
to  inform  the  family  and  see  that  a  thorough 
formaldehyde  disinfection  is  made.  The  occa- 
sional disinfection  of  the  personal  effects  of  the 
patient  is  often  advisable.  In  case  of  decease  it 
is  always  best  that  everything  the  consumptive 
might  have  come  in  contact  with — furniture, 
bedding,  clothing,  books,  etc.,  should  be  thor- 
oughly disinfected.  In  many  communities  such 
disinfection  is  now  attended  to  by  the  board  of 
health. 

Where  the  aid  of  a  health  board  can  not  be 
secured,  the  following  directions  will  enable  one 
to  make  a  thorough  disinfection  by  formalde- 
hyde gas:  I.  All  cracks  or  openings  in  the  plas- 
ter, in  the  floor,  or  about  the  doors  or  windows 
should  be  caulked  tight  with  cotton  or  strips  of 
cloth.  2.  The  linen,  quilts,  blankets,  carpets, 
etc.,  should  be  stretched  out  on  a  line  in  order  to 
expose  as  much  surface  as  possible  to  the  disin- 
fectant. They  should  not  be  thrown  into  a  heap. 
Books  should  be  suspended  by  their  covers,  so 
that  the  pages  will  fall  open  and  be  freely  ex- 
posed. 3.  The  walls  and  the  floor  of  the  room  and 
the  articles  contained  in  it  should  be  thoroughly 
sprayed  with  water.  If  masses  of  matter  or 
sputum  are  dried  on  the  floor,  they  should  be 


46  TUBERCULOSIS 

soaked  with  water  and  loosened.  No  vessel  of 
water  should,  however,  be  allowed  to  remain  in 
the  room.  4.  One  hundred  and  fifty  cubic  centi- 
meters (live  ounces)  of  the  commercial  forty-per- 
cent solution  of  formalin  for  each  one  thousand 
cubic  feet  of  space  should  be  placed  in  the  dis- 
tilling apparatus  and  be  distilled  as  rapidly  as 
possible.  The  keyhole  and  spaces  about  the  door 
should  then  be  packed  with  cotton  or  cloth. 
5.  The  room  thus  treated  should  remain  closed 
at  least  ten  hours.  If  there  is  much  leakage  of 
gas  into  the  surrounding  rooms,  a  second  or 
third  distillation  of  formalin  should  be  made  at 
intervals  of  two  or  three  hours. 

Whether  the  patient  is  treated  at  home  for  a 
little  while  or  all  the  time,  the  supervision  and 
guidance  of  the  physician  are  essential.  Whether 
the  patient  himself  will  be  competent  to  carry  out 
all  the  instructions  given  or  whether  it  will  be 
necessary  for  a  member  of  the  family,  a  friend, 
or  a  trained  nurse  to  help  the  doctor,  will  depend 
upon  the  individual  case.  The  extent  of  the  dis- 
ease, the  character,  the  disposition,  and  the  social 
environrhents  of  the  patient  will  all  have  to  be 
taken  into  consideration. 

As  has  Ijcen  said  in  the  preface,  this  book  is  not 
intended  to  replace  the  physician,  and  the  follow- 
ing instructions  are  only  given  to  aid  the  physi- 


GENERAL  ADVICE  47 

cian  in  a  general  way  and  give  him  a  foundation 
to  which  to  add  the  more  minute  and  individual 
advice  each  case  may  demand.  Some  of  the 
necessary  precautions  indicated  in  this  general 
advice  have  been  already  dw^lt  on  in  Chapter  I. 
They  are  repeated  here  because  of  the  conviction 
that  when  they  are  given  by  the  physician  of 
the  family,  their  chances  of  being  obeyed  are 
materially  increased. 

General  Advice  to  the  Consumptive  Patient. 

Be  hopeful  and  cheerful,  for  your  disease  can  be 
cured. 

Avoid  anxiety  and  worry  as  far  as  possible. 

Do  not  talk  to  any  one  about  your  disease  or  symp- 
toms except  to  your  physician  or  nurse. 

When  indoors  remain  in  the  sunniest  and  best  venti- 
lated room.  It  is  better  to  have  no  carpets  or  heavy 
hangings  in  the  room ;  small  rugs  and  washable  curtains 
may  be  allowed.  Cleaning  should  be  done  in  such  a 
way  as  not  to  raise  any  dust  in  the  room. 

Never  sleep  or  stay  in  a  hot  room.  Have  your  own 
sleeping  room  if  possible,  but  always  have  your  own 
bed,  which  should  be  freely  aired  during  the  daytime. 
In  cold  weather  you  may  have  a  fire  in  the  room,  but 
keep  the  window  wide  enough  open  not  to  have  the 
room  warmer  than  60°  to  65°  F. 

Keep  at  least  one  window  always  open  in  your  bed- 
room. Night  air  is  as  good  and  in  cities  even  better 
than  day  air. 


4^  TUBERCULOSIS 

Have  at  least  nine  hours'  sleep  in  the  twenty-four  and 
retire  early.  If  you  have  to  work  during  the  week  and 
feel  as  if  you  do  not  get  a  sufficient  amount  of  rest,  re- 
main in  bed  all  Sunday  morning  and  get  thoroughly 
rested. 

If  you  are  directed  to  sleep  outdoors  in  a  tent,  on  a 
veranda,  on  a  porch,  or  in  a  window  tent,  begin  gradu- 
ally, and  in  cold  weather  be  particular  to  dress  warmly 
for  the  night  and  have  plenty  of  bed  covering.  Your 
feet  must  be  kept  warm. 

Remain  in  the  sunshine  as  much  as  possible,  except 
in  very  hot  weather;  but  always  protect  your  head.  If 
there  is  no  sheltered  spot  outdoors  or  on  a  veranda,  the 
best  place  to  take  a  sun-bath  is  in  front  of  the  open  win- 
dow. Extend  yourself  on  a  comfortable  lounge  with 
your  head  in  the  shade  and  the  body  bathed  by  the  rays 
of  the  sun;  remain  there  as  long  as  you  feel  comfortable. 

A  feeling  of  discomfort,  headache,  or  a  rise  of  tem- 
perature are  an  indication  that  you  have  been  exposed 
too  much  to  the  sun  and  that  you  must  seek  the  advice 
of  the  physician  before  resuming  the  sun-baths. 

Live  as  much  as  you  can  in  the  open  air.  Do  not  be 
afraid  of  cold  weather;  in  snowy  or  rainy  weather  always 
wear  rubber  shoes  and  an  outer  garment  which  will 
keep  you  dry  and  warm.  Remain  indoors  only  on  very 
windy  and  stormy  days. 

The  rest  cure  in  the  open  air  on  a  reclining  chair  can 
and  should  be  taken  in  all  kinds  of  weather,  providing 
you  protect  yourself  against  rain  or  too  strong  winds. 
Whether  you  are  taking  your  rest  cure  outdoors  during 


GENERAL  ADVICE  49 

the  day,  are  sleeping  outdoors,  in  a  window-tent,  or 
in  a  room  with  the  windows  wide  open,  if  you  suffer 
from  the  cold,  it  is  time  to  return  to  the  house  or  close 
part  of  the  window.  Protect  yourself  better  the  next 
time,  for  the  air  does  not  do  you  any  good  when  you 
become  chilled. 

Dress  yourself  comfortably,  but  not  so  heavily  as  to 
hinder  your  movements.  Discard  chest-protectors,  for 
they  only  tend  to  make  you  take  colds  more  easily. 
Wear  a  suit  of  linen-mesh  underwear;  but  do  not  change 
from  wool  to  linen  in  cold  weather  unless  you  begin  by 
wearing  the  linen-mesh  next  the  skin  and  some  warmer 
under-garment  of  cotton  or  wool  over  it.  Keep  your 
feet  dry  and  warm,  particularly  when  you  are  taking  the 
rest  cure  in  the  open  air  in  cold  weather.  Use  a  heated 
soapstone  or  hot  water  bag  if  necessary. 

Take  a  bodily  and  mental  rest  on  your  comfortable 
reclining  chair  for  about  thirty  minutes  before  and  after 
the  principal  meals. 

Do  not  take  any  kind  of  medicine  (patent  or  other), 
peculiar  food-substances,  or  exercises,  except  such  as 
are  prescribed  by  your  physician. 

Avoid  all  unnecessary  exertions,  mental  or  physical. 
Avoid  exciting  conversation.  Never  run  nor  lift  heavy 
weights.  Never  take  any  exercises  when  you  are  tired, 
nor  take  them  to  the  extent  of  getting  tired.  Avoid  get- 
ting into  perspiration. 

When  walking  against  the  wind,  riding  in  carriage  or 
automobile,  do  not  converse  but  keep  your  mouth 
closed  and  breathe  through  the  nose  only. 


so  '  TUBERCULOSIS 

Take  your  walking  exercises  as  you  have  been  di- 
rected, and  when  feasible  begin  with  walking  slowly 
uphill;  the  return  will  then  be  easier. 

Take  your  breathing  exercises  regularly  as  pre- 
scribed; always  breathe  through  the  nose. 

Avoid  strong  draughts,  dust,  and  dampness,  and  all 
places  where  the  air  is  bad,  such  as  theaters,  concert 
halls,  crowded  meeting  places,  etc. 

In  cold  weather  bathe  and  dress  in  a  warm  room. 
If  you  sleep  in  a  tent,  have  a  fire  made  before  rising;  if 
on  a  veranda,  have  your  bed  rolled  into  a  warm  room 
or  go  there  quickly,  covering  yourself  with  a  coat 
or  blanket.  If  you  sleep  in  a  window-tent,  close 
the  window  and  wait  until  the  room  is  sufficiently 
warm  before  dressing.  As  a  rule  in  winter  do  not 
leave  the  house  until  an  hour  after  sunrise,  because 
the  air  before  that  time  is  usually  very  much  colder. 
By  taking  these  precautions  you  will  avoid  being 
chilled. 

Try  to  control  your  cough.  You  should  train  your- 
self to  cough  only  when  you  have  to  expectorate. 

All  expectoration,  discharges  from  the  lungs  and 
throat,  contain  germs.  Some  of  these,  especially  when 
there  is  throat,  bronchial,  or  lung  trouble,  are  dangerous. 
Thus,  it  is  best  to  be  careful  and  gather  all  the  ex- 
pectoration, of  whatever  nature,  and  destroy  it  before 
harm  can  be  done  by  it.  To  this  end  one  should  always 
expectorate  in  a  proper  receptacle  and  see  to  it  that  its 
contents  are  destroyed.  Carelessness  in  this  respect  is 
sure  to  cause  the  spread  of  the  disease  to  others.    This 


GENERAL  ADVICE  51 

method  of  disposing  of  the  sputum  also  protects  the 
patient  himself  from  taking  the  same  germs  into  his 
system  again,  either  by  inhaling  dust  containing  parti- 
cles of  the  dried  sputum  or  by  infecting  himself  through 
sores.  Be  particularly  careful  when  you  have  any 
wound  or  scratch  on  your  hands,  for  if  tuberculous 
matter  comes  in  contact  with  an  open  wound  local  in- 
fection, or  inoculation,  may  take  place.  It  is  not  safe  to 
use  a  handkerchief  to  spit  into  since  in  this  way  an  in- 
fection of  the  nose  is  possible. 

When  at  home  always  expectorate  in  a  spittoon  filled 
partially  with  water,  or  better,  with  water  into  which 
you  have  put  one  part  of  carbolic  acid  to  twenty  parts 
of  water  (five  per  cent  solution).  When  you  can  not 
conveniently  get  at  the  stationary  spittoon  use  a  pocket 
spittoon.  When  away  from  home  or  if  the  use  of  such  a 
pocket  flask  or  spittoon  is  not  practicable,  use  squares 
of  muslin  simulating  handkerchiefs,  or  use  Japanese 
handkerchiefs  to  expectorate  into.  Keep  them  in  a 
leather  pouch  or  in  a  pocket  lined  with  impermeable 
material  until  you  can  burn  them  on  your  return  home. 
Ladies  should  divide  their  handbags  into  two  compart- 
ments to  serve  the  same  purpose.  For  people  who  five 
in  flats  where  the  cooking  is  done  over  gas,  it  may  be 
difficult  to  find  a  place  to  burn  the  cheap  handkerchiefs, 
rags,  pasteboard  pocket  spittoons,  or  paper.  While  the 
thin  paper  might  be  thrown  into  the  water-closet,  this 
can  not  be  done  with  rags  or  pasteboard.  Individuals 
thus  situated  should  use  thin  paper  which  they  can 
throw  into  the  water-closet,  or  a  pocket  flask  of  metal  or 


52  TUBERCULOSIS 

glass  which  snould  be  emptied  into  the  closet  and 
cleaned  ^Yith  hot  water.  There  are  small  and  conven- 
ient ones  to  be  had  that  can  be  hidden  in  the  folds  of 
a  handkerchief  when  used. 

All  stationary  spittoons  should  be  covered,  for  flies 
and  other  insects  may  crawl  over  them,  partake  of  the 
tuberculous  matter  and  by  depositing  the  latter  on  arti- 
cles of  food  or  elsewhere,  become  propagators  of  tuber- 
culosis. 

Whether  sick  or  well  never  expectorate  on  the  side- 
walk but  always  in  the  gutter  if  there  is  no  spittoon. 

Never  swallow  your  expectoration.  Never  use  the 
same  handkerchief  to  wipe  your  nose  which  you  use  to 
wipe  your  mouth  after  having  expectorated.  Always 
cover  your  mouth  with  a  handkerchief  or  the  hand 
while  coughing  or  sneezing.  Never  kiss  any  one  on  the 
mouth  nor  allow  it  to  be  done  to  you. 

Handle  soiled  personal  and  bed  linen,  especially 
handkerchiefs,  as  little  as  possible  in  the  dry  state. 
When  soiled,  place  these  articles  in  water  until  ready  to 
be  washed. 

It  is  best  not  to  wear  any  mustache  or  beard,  but  if 
worn  they  should  be  closely  clipped. 

Always  wash  your  hands  thoroughly  before  touching 
food. 

Directions  Concerning  Food,  Drink,  Stimulants, 

ETC. 

Live  on  a  mixed  diet,  that  is  to  say,  meal,  fish,  oys- 
ters, vegetables,  especially  spinach,  lentils,  cauliflower; 


GENERAL  ADVICE  53 

fresh  and  cooked  fruit,  particularly  grapes;  plenty  of 
fresh  milk,  fresh  eggs;  all  sorts  of  easily  digested  fats, 
especially  butter.  Thick,  nourishing  soups  should  be 
eaten  with  the  principal  meals.  Raw,  chopped  or 
scraped  beef  is  especially  to  be  recommended.  Whole- 
wheat bread  being  more  nourishing  than  white  bread, 
is  to  be  preferred.  Do  not  cat  the  inside  of  fresh  bread; 
bread  with  a  hard  crust,  toast  and  stale  bread  are  more 
easily  digested  and  more  nourishing. 

Eat  slowly,  chew  your  food  well,  take  the  milk  in 
small  swallows;  take  but  little  liquid  during  and  shortly 
after  meals.  Keep  your  teeth  in  good  condition;  use 
toothpick  and  brush  after  each  meal. 

Never  take  any  alcoholic  beverages  (wine,  beer,  or 
liquor)  without  special  consent  and  the  direction  of 
your  physician.  Too  much  sweets  (sugar,  pies,  pastry, 
etc.)  should  also  be  avoided,  as  well  as  all  kinds  of  fried 
food. 

Drink  plenty  of  good,  pure  water  between  meal- 
times. 

Do  not  use  tobacco  in  any  form;  smoking  cigarettes 
and  inhaling  the  smoke  is  particularly  injurious. 

Directions  Concerning  Baths  and  the  Use  of 
Cold  Water. 

Take  a  short  warm  bath  once  a  week,  followed  by  a 
rapid  sponging  with  cool  water  and  a  vigorous  rubbing 
with  a  rough  towel. 

Wash  your  neck  and  chest  every  morning  with  cold 
water. 


54  TUBERCULOSIS 

Take  a  cold  douche  every  morning  when  so  directed 
by  your  physician.  If  the  reaction  does  not  follow  rap- 
idly, seek  his  advice. 

Special  Advice  to  the  Patient,  Nurse,  and  the 

Family 

Any  intercurrent  trouble,  such  as  fever,  indigestion, 
diarrhoea,  constipation,  increased  cough,  pain,  reddish 
expectoration,  or  hemorrhage,  should  be  at  once  re- 
ported to  the  physician.  Do  not,  however,  be  alarmed 
if  a  hemorrhage  occurs,  as  it  is  but  one  of  the  phases  of 
the  disease,  and  does  not  lessen  the  chances  for  re- 
covery. Let  the  patient  remain  quiet  on  a  reclining 
chair  or  on  the  bed  and,  until  the  arrival  of  the  physi- 
cian, place  a  cold  compress  or  ice  bag  over  the  heart. 
In  case  of  fever,  particularly  when  it  is  as  high  as 
1 00°  or  more,  it  is  best  for  the  patient  to  go  to  bed 
and  await  instructions  from  the  physician. 

A  careful  and  obedient  patient  has  all  possible 
chances  of  getting  well,  while  he  who  is  careless  and 
disobedient  may  forfeit  all  possibility  of  recovery. 

To  All  Whom  It  May  Concern 
The  careful,  clean,  and  conscientious  consumptive 
who  is  trained  in  the  prevention  of  the  disease,  is  not 
dangerous  to  those  with  whom  he  may  live  and  work. 
Signature  of  the  Attending  Physician. 

The  conscientious  physician  to  whom  the  tuber- 
culous patient  comes  for  treatment,  v^ill  not  content 
himself  with  merely  giving  directions  how  to  live 


SPECIAL  ADVICE  55 

and  what  to  eat,  or  prescribing  medicine  if  such 
is  needed.  He  will  realize  that  he  can  not  treat 
the  patient  successfully  without  having  a  knowl- 
edge of  the  latter's  home  environments.  While 
the  patient  may  be  well  enough  to  get  about 
(ambulant)  and  to  come  regularly  to  the  phy- 
sician's office  to  report  or  be  reexamined,  to  see 
the  patient  occasionally  in  his  home  and  talk  with 
those  with  whom  he  is  living,  is  an  essential  part 
of  the  judicious  management  of  a  tuberculous 
case. 

The  physician  will  not  infrequently  have  to 
enter  into  the  very  soul  life  of  the  patient.  To 
keep  him  hopeful  and  of  good  cheer  he  will  often 
have  to  appeal  for  help  to  those  living  or  associ- 
ated with  the  patient.  Worry  and  anxiety  should 
as  far  as  practicable  be  removed  from  the  sick. 
A  brooding  mind  is  the  worst  thing  for  a  con- 
sumptive, for  he  will  not  eat  nor  breathe  as  he 
should  and  his  digestion  will  become  more  and 
more  impaired.  The  more  cheerful  the  physician 
is  himself,  the  more  hope  and  genuine  sympathy 
he  has  as  an  equipment  for  his  calling,  the  more 
certain  will  he  be  to  benefit  the  tuberculous  in- 
valid. 


CHAPTER  IV 

HOW  THE  SANATORIUM  TREATMENT  MAY  BE 
ADAPTED  TO  AND  IMITATED  IN  THE  HOME  OF 
THE   CONSUMPTIVE 

Many  cases  of  tuberculosis,  some  among  the 
well-to-do  and  some  among  the  poor,  will  have 
to  be  treated  at  home;  and  when  this  is  necessary 
w^e  must  seek  to  imitate  in  the  home  the  methods 
in  vogue  in  sanatoria  where,  so  far,  the  best  re- 
sults have  been  obtained  in  the  treatment  of  tuber- 
culosis. 

The  first  thing  in  all  cases  is  to  see  that  the  pa- 
tient is  properly  housed.  Among  the  well-to-do 
and  those  having  their  own  house,  he  should  have 
two  or  three  rooms  on  an  upper  floor  at  his  dis- 
posal. In  all  cases  where  this  is  not  feasible, 
select  the  best  lighted  and  best  ventilated  room, 
preferably  with  southern  exposure,  for  the  pa- 
tient to  sleep  in.  It  goes  without  question  that 
even  in  the  poorest  family  the  patient  should 
have  his  own  bed,  and  if  he  is  in  the  latter  stage  of 
the  disease  and  obliged  to  spend  day  and  night  in 
bed,  nothing  will  be  so  pleasant  for  him  as  to 

56 


TREATMENT  AT  HOME  57 

have  two  beds  at  his  disposal,  one  to  rest  in  during 
the  day  and  one  to  sleep  in  during  the  night.  The 
furniture  should  be  plain  and  simple,  the  chairs 
of  wood,  cane  seated  or  leather  covered.  Plush 
furniture  or  any  dust-catching  material,  heavy 
curtains,  and  fixed  carpets  should  be  avoided. 
Still,  the  room  need  not  be  made  cheerless.  A 
few  small  rugs,  washable  curtains,  and  some 
cheerful  pictures  to  decorate  the  w^all  should  be 
allowed. 

As  the  most  important  curative  agent  in  the 
modern  treatment  of  tuberculosis  we  must  first 
consider  fresh,  pure  air.  The  home  treatment 
can  be  made  most  successful  when  we  imitate,  as 
far  as  practicable,  all  the  salient  features  of  aero- 
therapy  as  practiced  in  the  sanatorium  treatment. 
In  these  institutions  the  patients  live  outdoors 
virtually  twenty-four  hours  of  the  day. 

Let  us  now  see  how  we  can  imitate  this  aero- 
therapy  of  the  sanatorium  treatment  in  the  home 
of  the  patient.  In  summer  we  have  all  the  win- 
dows open  and  during  the  day  we  place  our 
patient  in  the  yard,  on  the  veranda,  or  on  the 
roof,  whenever  and  wherever  conditions  permit 
us  to  have  him  take  what  is  known  as  the  rest- 
cure  in  the  open  air.  Here  he  rests  on  a  reclining 
chair  which  should  have  a  proper  knee  bend  and 
a  comfortable  back.    If  the  patient  can  afford  it, 


58 


TUBERCULOSIS 


we  get  him  also  a  half-tent.    (Fig.  15.)    This  half- 
tent  is  composed  of  a  frame  of  steel  tubing  which 

can  be  folded  together 
when  not  in  use.  Over 
this  frame  strong  sail 
duck  is  stretched  and  se- 
cured by  snap  buttons  on 
the  inside,  which  protects 
the  patient  against  wind 
and  sun.  To  prevent  the 
tent  from  being  over- 
turned by  the  wind,  the 
frame  has  ground  spikes 
holding  it  securely.  The 
reclining  chair  is  placed 
Fig.  15.    Knopf's  half-tent  for  in   this  half-tcnt  in  such 

the  rest-cure  m  the  open  air.     ^    manner    that     the     floor 
1  he  detachable  cover  is  made 

of  sail  canvas.    When  not  in  braciug   attached    to  the 

use  the  frame  may  be  folded    frame     is    held     down    by 
flat.  .  . 

the  chair,  which  adds  to 
its  security.  A  beach  chair  of  wickerwork  can 
also  be  made  to  do  the  service  of  the  half-tent. 
After  the  seat  has  been  removed,  the  inner  walls 
of  the  wicker  chair  are  lined  with  padding.  A 
reclining  chair  is  placed  with  its  back  in  the  in- 
terior, and  the  whole  arranged  so  that  the  patient 
is  protected  from  the  wind  and  sun.  Whenever 
the  patient  is  on  the  chair  he  should  be  so  com- 


TREATMENT  AT  HOME 


59 


fortable  as  to  allow  complete  muscular  relaxa- 
tion. Mind  and  body  must  be  at  rest.  For  poor 
patients  the  simple  steamer  chair  and  a  few  boards 
joined  together  to  support  the  canvas  will  have  to 
replace  the  more  costly  reclining  chair  and  half- 
tent.  A  large  and  stout  umbrella,  such  as  is  often 
used  at  seaside  resorts,  can  be  fastened  to  the  back 
of  the  steamer  chair  and  will  make  a  good  sub- 
stitute when  the  tent  can  not  be  provided. 

The  poor  patient  in  a  city  will  probably  be 
obliged  to  resort  to  the  roof  for  his  rest-cure,  as 
the  small  yard  of  a  tenement  house,  with  many 
children  playing  in  it,  will  scarcely  be  suitable. 
I  do  not  favor  the  use  of  the  fire  escape  for  this 
purpose.  A  recent  conflagration  in  the  city  of 
New  York  where  lives  were  lost  owing  to  the  ob- 
struction of  the  fire  escape,  showed  the  WTong  of 
evading  the  law  in  this  way.  On  the  reclining 
chair  in  the  open  air  the  patient  should  remain 
during  the  day  whenever  he  is  not  taking  any 
exercise.  In  the  modern  American  and  also  in 
some  European  sanatoria  the  majority  of  patients 
have  their  beds  moved  out  on  the  veranda  during 
the  night,  and  there  they  sleep  often  in  the  coldest 
weather.  That  excellent  results  are  obtained  from 
sleeping  outdoors  in  cold  weather  when  everything 
is  carefully  arranged,  is  now  a  well-established  fact. 

When  the  patient  has  his  own  home  and  lives 


6o 


TUBERCULOSIS 


Fig.  i6.     Sleeping  Balcony  Designed  and  Used  by  a  Young  Tubercu- 
lous Chemist  of  Boston. 

in  a  village  or  small  town,  it  is  often  very  easy  to 
arrange  for  sleeping  on  the  veranda.  Even  a 
special  porch  for  the  exclusive  use  of  the  patient 
can  often  be  built  with  relatively  little  expense. 
The  accompanying  picture  (Fig.  i6)  shows  such  a 
porch  which  was  devised  by  a  young  Massachu- 
setts chemist,  himself  a  sufferer.  Realizing  the 
value  of  fresh  air  treatment  by  day  and  l)y  night, 
he  had  an  outdoor  bedroom  constructed  which 
was  built  in  the  south  corner  between  the  ell  and 
the  main  portion  of  his  house,  covered  at  the  top 


PROPER  HOUSING  6i 

and  open  on  two  sides.  The  dimensions  of  this 
little  room  were  approximately  6  by  lo  feet;  it 
was  firmly  secured  along  two  sides  to  the  house, 
and  supported  at  the  outer  corner  by  a  stout 
timber  from  the  ground.  For  the  height  of  about 
2 1  feet  from  the  floor  there  was  a  sheathed  wall, 
the  rest  being  open  to  the  roof,  which  had  a  wide 
overhang  to  prevent  as  far  as  possible  the  dripping 
in  of  the  rain.  Curtains  of  canvas  were  provided, 
which  pulled  up  from  beneath,  but  which  were 
used  only  in  case  of  storm  or  wind.  The  window 
was  cut  down  into  a  door  to  provide  easy  access 
from  the  house.  This  room  was  simply  con- 
structed, the  outer  wall  being  of  pine  sheathing. 
It  had  a  tight  double  floor.  The  interior  was  a 
natural  wood  finish  with  no  attempt  to  hide  the 
rough  beams,  and  the  roof  was  covered  with  heavy 
roof  paper  known  as  rubberoid .  The  total  expense 
for  construction  and  painting  was  about  $104. 
The  location  of  the  room  was  such  that  it  was  thor- 
oughly protected  from  the  north  and  west  winds, 
and  the  situation  of  the  house  was  quite  favorable 
in  that  it  was  surrounded  by  open  areas  with 
numerous  trees.  A  much  simpler  and  less  ex- 
pensive construction  is  shown  in  Fig.  17,  repre- 
senting an  original  sleeping  balcony  in  Hanover, 
Mass.,  used  since  June,  1898. 

When  the  building  of  a  special  veranda  or  porch 


62 


TUBERCULOSIS 


Fig.  17.     Original  Sleeping  Balcony  in  Hanover,  Mass.,  Used  Since 

June,  1898. 

is  not  feasible  and  there  is  plenty  of  ground 
around  the  house,  a  so-called  shack  can  be  built 
and  turned  into  most  comfortable  sleeping  quarters 
for  a  patient.  One  of  the  latest  and  most  practical 
shacks  I  have  seen  is  the  one  designed  by  Dr. 
Millet  of  Brockton,  Mass.,  to  whom  I  am  in- 
debted for  the  illustration  (Figs.  18  and  19)  and 
description  of  this  construction,  so  valuable  in  the 
treatment  of  the  consumptive  at  home. 

The  following  description  will  aid  any  one  in 
a  position  to  have  such  a  shack  to  know  how 
to  build  it.  It  should  ])e  remembered  that  the 
shack  for  tuberculous  patients  must  have  all  the 
air  and  sun  which  can  possibly  ])e  admitted  to  it, 
consistently  with  shelter    from   rain,   snow,  and 


PROPER  HOUSING 


6S 


Fig.  i8.     Latest  Model  of  Sleeping  Shack  Designed  by  Dr.  Millet  of 

Brockton,  Mass. 


<5(XJTri     D-tVATION 


Cast  Clzva.tion 


Fig.  19.     Dr.  Millet's  Shack.     South  and  East  Elevations. 


64  TUBERCULOSIS 

violent  winds.  For  this  purpose  it  should  face  the 
south;  the  front  should  be  as  open  as  possible, 
and  should  be  much  higher  than  the  back,  so 
that  the  sun's  rays  may  reach  all  parts  of  the  in- 
terior. There  should  be  openings  on  all  the  other 
sides  to  give  cross-currents  of  air,  although  all  the 
openings,  except  those  toward  the  south,  should 
have  provision  for  closing  them  in  cold  and  stormy 
weather.  Even  the  south  openings  should  have 
screens  of  some  sort  for  protection  against  south- 
erly rains,  but  they  will  not  often  be  brought  into 
use.  If  the  shack  is  near  a  dwelling  house  which 
the  patient  can  reach  easily,  nothing  more  than  a 
simple  structure,  12  feet  square,  with  three  walls, 
a  roof  and  floor,  standing  on  posts,  and  costing 
about  Sioo  complete,  will  be  required;  but  for 
greater  comfort,  especially  for  patients  unable  to 
walk  far,  a  dressing  room  may  be  added  for  about 
double  the  cost,  such  as  is  shown  in  the  picture 
of  Dr.  Millet's  shack.  This  building  is  12  by 
18  feet,  supported  on  cedar  posts,  boarded  and 
covered  with  shingles,  with  a  shingled  roof.  It 
faces  due  south,  and  the  roof  rises  toward  the 
front  at  an  angle  with  the  horizon  of  26^7  degrees, 
known  to  builders  as  'Vjuartcr  pitch."  The  in- 
terior is  divided  into  a  bedroom  12  by  12  feet, 
and  a  dressing  room  6  ])y  12  feet.  The  front  of 
the  bedroom  is  entirely  open.    Sashes  can  be  fitted 


PROPER  HOUSING  65 

into  the  spaces  between  the  posts  if  thought  neces- 
sary, but  experience  shows  that  they  are  not 
required;  hght  screens,  covered  with  paraffined 
cloth,  are  found  sufficient  to  exclude  rain  and 
snow.  These  screens  are  hinged  to  the  top  of  the 
openings  and  are  drawn  up  to  the  under  side  of  the 
roof  when  not  in  use.  The  north  wall  of  the  bed- 
room is  about  6i  feet  high,  and  has  three  openings, 
closed  in  bad  weather  by  hinged  w^ooden  shutters. 
Toward  the  wTst  is  the  door  from  the  outside 
and  a  window,  and  on  the  east  is  a  sliding  door 
leading  into  the  dressing  room  which  has  a  window 
opposite  the  door  and  also  a  south  window\  In 
the  dressing  room  is  a  chimney  and  a  stove,  a 
set  washbasin  wath  running  water,  a  water-closet, 
and  a  movable  bureau,  and  a  wardrobe.  In 
pleasant  weather  the  windows  and  door  of  the 
dressing  room  are  kept  open;  in  cold  weather 
they  are  closed  so  that  the  water  pipes  may  not 
freeze;  but  the  bedroom  openings  are  practically 
never  closed.  Except  that  of  the  chimney,  the 
whole  construction  is  of  wood.  There  is  no  plas- 
tering, the  partitions  being  of  wood  sheathing. 
The  floor  is  double,  the  upper  floor  being  of  nar- 
row rift  North  Carolina  pine.  The  cost  of  this 
structure  is  $300,  including  the  chimney,  stove, 
and  plumbing. 

In  places  where  the  climate  is  relatively  dry, 


66 


TUBERCULOSIS 


some  sort  of  a  tent  may  also  serve  the  purpose  of 

outdoor  living.     Figure  20  is  an  illustration  of  a 

suitable  tent  with  a  wooden  floor. 

With  the  devices  just  described,  the  open  air 

cure  can  be  carried  out  day  and  night  in  a  small 

town  or  village,  even 
in  the  homes  of  the 
relatively  poor,  with 
ease  and  little  cost. 

What  worried  me 
for  years  was  the  fact 
that  we  could  provide 
this   open  air  trcat- 

FiG.  20.    The  Tucker  Tent  Tor  CJut-     YXieut      at       night       for 
door  Living.  1    i.-      1  n 

such  a  relatively  small 
number  of  patients  in  our  large  cities,  when  there 
are  so  many  who  need  it  particularly  among  the 
consumptive  poor.  I  believe  I  have  been  fortu- 
nate enough  to  solve  this  problem  in  a  measure  by 
an  unpretentious  device  which  I  call  a  'Svindow- 
tent."  After  much  experimenting,  modelling,  and 
remodelling  to  overcome  the  defects  which  I 
learned  through  my  own  experience  and  that  of 
others  in  the  use  of  the  tent,  I  believe  I  am  able 
to  present  to  the  profession  and  to  the  public  a 
model  as  nearly  complete  and  perfect  as  possil3le. 
Many  of  the  unfortunate  poor  will,  however,  not 
even  be  able  to  pay  the  modest  price  at  which 


WINDOW-TENTS 


67 


Fig.  21.  Knopf's  window- tent  for  the  open  air  treatment  of  tuber- 
culous patients.  Tent  in  use  with  patient  in  bed  looking  through 
the  celluloid  window  into  the  room,  but  breathing  outdoor  air  only. 

the  window-tent  is  now  put  on  the  market,  but 
with  the  illustrations  before  them  they  may  have 
sufficient  mechanical  skill  to  imitate  the  device  at 
very  little  cost. 

As  will  be  seen,  this  window-tent  (Fig.  21)  is  an 
awning  which,  instead  of  being  placed  outside  of 
the  window,  is  attached  to  the  inside  of  the  room. 
It  is  so  constructed  that  the  air  from  the  room 
can  not  enter  or  mix  with  the  air  in  the  tent.    The 


68 


TUBERCULOSIS 


patient  lying  on  the  bed,  which  is  placed  parallel 
with  the  window,  has  his  head  and  shoulders 
resting  in  the  tent.     By  following  the  description 

closely,  it  will  be  seen 
(Fig.  22)  that  the  venti- 
lation is  as  nearly  per- 
fect as  can  be  produced 
with  so  cheap  a  device. 
The  tent  is  placed  in 
the  lower  half  of  an 
American  window,  but 
it  does  not  quite  fill  the 
lower  half  of  the  frame ; 
a  space  of  about  three 
inches  is  left  for  the 
escape  of  the  warm  air 
in  the  room.  By  lower- 
ing the  window,  this 
space  can  be  reduced 
to  one  inch  or  less,  ac- 
cording to  need.  On 
extremely  cold  and 
windy  nights  there  need 
not  be  left  any  open 
space  at  all  above  the  tent  frame.  The  patient's 
breath  will  rise  to  the  top  of  tlic  tent,  the  form 
of  which  aids  in  the  ventilation.  The  tent  is  con- 
structed of  a  series  of  four  frames,  made  of  Bcsse- 


P'lG.  22.  Sectional  View  Showing 
the  Ventilation  of  Knopf's  Win- 
dow-Tent. 


WINDOW-TENTS  69 

mer  rod  suitably  formed  and  furnished  with 
hinged  terminals,  the  hinges  operating  on  a  stout 
hinge  pin  at  each  end  with  suitable  circular  wash- 
ers to  insure  independent  and  easy  action  in 
folding. 

The  frame  is  fitted  with  a  cover  of  extra  thick 
yacht  sail  twill  having  elongated  ends,  to  admit 
of  their  being  tucked  in  under  and  around  the 
bedding  to  prevent  the  cold  air  from  entering  the 
room.  The  patient  enters  the  bed  and  then  the 
tent  is  lowered  over  him;  or  with  the  aid  of  a 
cord  and  a  little  pulley  attached  to  the  upper 
portion  of  the  window,  he  can  manipulate  the 
lowering  and  raising  of  the  tent  himself.  Shutters 
and  Venetian  blinds,  whether  they  are  attached 
on  the  inside  or  on  the  outside  of  the  window, 
can  be  utilized  in  conjunction  with  the  window- 
tent  as  a  screen  to  intercept  the  gaze  of  the 
neighbors  (Fig.  23),  and  in  stormy  weather  as  a 
protection.  The  bed  can  be  placed  by  the  window 
to  suit  the  patient's  preference  for  sleeping  on 
his  right  or  left  side,  so  that  he  has  the  air  most 
of  the  time  in  his  face.  The  bed  being  placed 
alongside  of  the  window  will  be  convenient  for  a 
majority  of  the  poor  who  have  small  rooms.  If, 
however,  the  bed  must  be  placed  at  a  right  angle  to 
the  window,  this  can  be  arranged  as  well.  A  piece 
of  transparent  celluloid  is  placed  in  the  middle 


70 


TUBERCULOSIS 


portion  of  the   tent  to  serve  as  an  observation 
window  for  the  nurse  or  members  of  the  family 

to  watch  the  pa- 
tient if  this  is  nec- 
essary.  It  also 
SLTvcs  to  make  the 
patient  feel  less 
outdoors  and  more 
in  contact  with  his 
family.  He  can, 
if  he  desires,  see 
what  is  going  on 
in  the  room.  If 
the  window-tent 
must  be  placed  at 
a  right  angle  to 
the  window,  the 
observation  glass 
can  be  put  in  on  the  side.  It  is  a  general  rule  that 
patients  should  not  smoke;  when,  in  exceptional 
cases,  this  can  be  allowed,  the  danger  of  the  cel- 
luloid window  becoming  ignited  must  be  impressed 
upon  them  and  the  greatest  caution  urged.  I 
prefer  celluloid  to  glass  because  there  is  no  danger 
of  cuts  or  scratches  with  the  possibility  of  tuber- 
culous inoculation,  as  there  would  be  if  the  glass 
should  break. 

If  it  is  necessary  to  raise  the  bed  to  the  height 


Fig.  23.    \'ie\v  of  the  Window-Tent  and 
Patient  Taken  from  the  Outside. 


WINDOW-TENTS 


71 


Fig.  24.     Knopf's  Window-Tent  Raised  When  Not  in  Use. 

of  the  window-sill,  this  can  be  done  with  little 
expense.  If  the  bed  is  of  iron,  a  few  additional 
inches  of  iron  piping  can  be  attached  to  the  legs 
by  any  plumber  or  one  handy  with  tools;  raising 
a  wooden  bed  can  be  accomplished  with  equal 
facility.  If  the  window-tent  is  to  serve  the  patient 
only  during  the  night,  it  can  be  pulled  up  (Fig.  24) 
and  the  bed  moved  away  from  the  window  during 
the  day,  and  the  window  closed.  Or  the  tent  can 
be  taken  from  the  hooks  and  put  out  of  the  way. 
The  window-tent  will,  of  course,  be  of  greatest 
service  to  the  consumptive  sufferer  in  winter.  If 
he  is  feverish,  or  his  stay  in  bed  is  advisable,  he 
can  spend  his  entire  time  in  the  window-tent.    If 


72  TUBERCULOSIS 

the  people  are  poor  and  the  room  where  the  con- 
sumptive sufferer  hes  serves  as  hving  room  for 
the  rest  of  the  family,  the  fact  that  the  well  mem- 
bers need  not  shiver  and  yet  the  patient  can  take 
his  open  air  treatment,  is  of  vital  importance  in 
many  respects.  While  the  room  will  not  be  quite 
as  warm  as  if  the  window  was  entirely  closed,  it 
will  be  much  warmer  than  if  there  was  no  tent 
in  front  of  the  open  window.  Leaving  aside  the 
economic  advantages  to  a  poor  family  when  not 
obliged  to  heat  more  than  one  room,  the  patient 
feels  that  he  does  not  deprive  his  loved  ones  of 
comfort  and  warmth,  and  that  he  is  less  a  burden 
and  hindrance  to  their  happiness.  The  other 
members  of  the  family,  on  the  other  hand,  feel 
that  they  can  give  the  patient  all  the  air  he  needs 
and  that  he  will  not  have  to  suffer  for  their 
comfort. 

Besides  the  just  mentioned  advantages,  there 
is  another  benefit  derived  from  the  use  of  the 
window -tent  arrangement  which  will  add  to  the 
patient's  physical  and  mental  comfort.  His  pro- 
longed rest  cure  in  bed  will  be  more  endurable 
when  he  is  permitted  to  look  out  on  the  street 
and  watch  life  there,  than  when  ol^liged  to  gaze 
at  the  four  walls  of  his  room.  An  important  ad- 
vantage which  the  window-tent  offers  is  the  fol- 
lowing: patients  who  can  only  be  persuaded  with 


WINDOW -TENTS  73 

difficulty  to  sleep  with  the  window  wide  open 
will  not  hesitate  when  they  have  this  tent  as  an 
inducement.  Draught,  which  the  consumptive 
patient  usually  dreads,  particularly  in  cold  weather 
and  when  he  perspires,  need  not  be  feared  when 
sleeping  in  a  window -tent.  The  construction  is 
such  that  even  should  the  shoulders  be  accidentally 
exposed,  the  three  tent  walls  protect  the  patient 
from  violent  currents  of  air  which  may  be  pro- 
duced by  leaving  opposite  doors  in  the  room  open. 
In  this  respect  the  window- tent  even  has  an  ad- 
vantage over  sleeping  on  porches  when  they  are 
not  properly  inclosed. 

Lastly,  an  important  point  gained  by  the  use  of 
the  window-tent  for  consumptives  is  in  regard  to 
the  drop  infection  already  explained  in  Chapter  I. 
While,  as  a  matter  of  course,  the  patient  will 
have  been  taught  always  to  hold  his  hand  or 
handkerchief  before  his  mouth  when  he  coughs 
or  sneezes,  this  is  not  always  done  and  can  not 
be  done  when  coughing  in  sleep.  To  limit  the 
possible  infection  to  the  interior  of  the  window- 
tent  is  obviously  a  great  advantage.  First,  the 
constant  exposure  to  air  and  light  of  the  bacilli 
which  may  have  been  expelled  with  the  saliva 
and  remain  adherent  to  the  canvas,  will  soon 
make  them  innoxious;  secondly,  the  canvas  of  the 
tent  is  attached  to  the  frame  by  simple  bands,  and 


74  TUBERCULOSIS 

its  removal  from  the  frame  for  thorough  cleansing, 
washing,  or  disinfection  is  thus  made  easy. 

Another  ingenious  device,  which  can  be  applied 
very  easily  in  a  country  town  and  in  private 
houses,  is  Bull's  aerarium.  The  fact  that  this 
device  was  not  exactly  suitable  for  consumptive 
dwellers  in  the  tenement  houses  of  a  great  city 
caused  me  to  think  out  the  window-tent  just  de- 
scribed. The  aerarium  of  Dr.  Bull  is  a  double 
awning  attached  to  the  outside  of  the  window  with 
a  special  ventilating  arrangement.  (Fig.  25.) 
The  head  of  a  cot-bed  is  put  through  the  window 
and  thus  the  patient's  head  rests  out  of  doors. 
(Fig.  25a.) 

The  veranda  arrangement  for  the  outdoor  sleep- 
ing of  the  tuberculous  patients  was  first  suggested 
and  carried  out  by  Dr.  C.  S.  Millet  of  Brockton, 
Mass.,  who  showed  that  this  could  be  done  with 
benefit  to  the  patient  even  in  midwinter  in  the 
rigorous  climate  of  Massachusetts. 

In  cold  weather  the  patient's  bed  must  be 
covered  with  a  sufficient  number  of  blankets  to 
assure  his  absolute  comfort  and  warmth  through- 
out the  night.  Still,  the  covering  should  not  be 
so  heavy  as  to  press  down  upon  the  Ixxly  and 
make  the  patient  feel  uncomfortaljle  or  tire  him. 
The  tightly  woven  blanket  is  a  better  protection 
than  the  loosely  woven  one.     The  poor,  whose 


OPEN  AIR  TREATMENT 


75 


Fig.   25.      Bull's   Aerarium  for  the 
Open  Air  Treatment. 


Fig.  25a.     Sectional  View 
of  Bull's  Aerarium. 


supply  of  blankets  is,  alas,  often  very  limited, 
may  be  advised  to  put  several  layers  of  newspapers 
between  the  coverings  or  sew  a  dozen  layers  of 
newspapers  between  two  layers  of  dark  colored 
cotton  flannel.  In  extremely  cold  weather  the 
patient,  while  sleeping  in  the  window-tent  or 
any  other  outdoor  sleeping  device,  should  wear  a 
sweater  and  protect  his  head  and  ears  with  a 
woolen  cap,  shawl,  or  woolen  helmet,  such  as  is 
shown  in  the  accompanying  illustration.  (Fig.  26.) 
In  order  to  insure  absolute  warmth  for  the 
patients  sleeping  on  the  veranda,  in  an  open  shack, 


76 


TUBERCULOSIS 


or  in  the  window-tent,  it  may  sometimes  be  neces- 
sary to  resort  to  a  special  way  of  arranging  the 

bed.  There  exist  two  meth- 
ods of  making  a  bed  (which 
has  been  named  the  ''Klon- 
dike Bed")  suitable  for  out- 
door sleeping.  One  method 
which  originated  at  the 
Loomis  Sanatorium  is  as  fol- 
lows : 

Place  two  or    three  layers 
of  heavy  wrapping  or  build- 
ing paper  under  the  mattress. 
Several  layers  of  newspapers 
Fig.  26.    iiov.  to  Dress  ^ould  also  auswcr  the  pur- 
for  Outdoor  Sleeping  in   posc.    Placc  a  hcavy  blanket, 

Cold  Weather.  ^^j^     ^^^^^^^     ^^^^^^     ^j^^     ^^^ 

with  half  of  it  extended  over  one  side.  Place 
another  one  likewise  half  extending  over  the 
other  side  of  the  bed.  Now  use  a  thin,  wash- 
able double  blanket  lengthwise  with  closed  end 
at  foot.  This  one  is  to  sleep  between.  Have 
end  of  the  upper  half  of  this  blanket  extend  up 
to  head  of  the  bed  and  make  an  underfold  of 
the  corners  of  each  side  at  the  top.  Place  two 
or  three  heavy  double  blankets  lengthwise  of  the 
bed,  allowing  sufficient  on  the  top  one  to  tuck  in 
well  at  the  foot.    Now  fold  over  the  flaps  of  the 


OPEN  AIR  TREATMENT  77 

two  blankets  which  were  placed  crosswise  of  the 
bed  and  tuck  in  at  the  sides. 

In  getting  into  the  "Klondike"  bed  it  is  neces- 
sary to  slide  in  at  the  top  and  if  one  lies  on  his 
side,  the  blanket  which  he  is  between  (and  which 
was  placed  up  to  the  head  of  the  bed  with  corners 
folded  under)  can  be  used  to  bring  over  the  head 
and  under  the  shoulders,  tucking  the  opposite 
side  under  the  chin  so  that  the  face  only  is  exposed. 
This  is  considered  to  be  one  of  the  best  features 
of  this  method  of  making  the  bed.  The  blanket 
is  sufficient  covering  for  the  head,  and  for  a  quiet 
sleeper  more  comfortable  than  the  knitted  hood 
or  cap.  If  one  lies  on  his  back  a  thin  cap  would 
be  required  to  keep  the  ears  warm,  and  the  blanket 
can  be  tucked  in  around  the  neck.  The  bed  made 
in  this  way  can  not  easily  get  disarranged  and 
requires  to  be  made  over  entirely  about  twice  a 
week. 

Another  way  to  make  the  ''Klondike"  bed  is 
described  in  a  circular  on  the  Prevention  of 
Tuberculosis  issued  by  the  Illinois  State  Board 
of  Health.    This  method  is  as  follows: 

Make  the  bed  in  the  usual  way,  allowing  the 
coverings  to  fall  loose  on  either  side.  Now  gather 
up  the  coverings  on  one  side  and  pass  them  be- 
neath the  blanket  sheet  to  the  center  of  the  bed. 
Likewise  do  the  same  on  the  opposite  side.    Fold 


78  TUBERCULOSIS 

in  the  clothing  at  the  foot  of  the  bed  beneath  the 
blanket  sheet  and  the  Klondike  bag  is  ready  to 
sleep  in. 

The  usual  manner  of  placing  the  pillows  will 
be  found  unsuitable  for  cold  winter  nights,  when 
the  thermometer  drops  below  zero,  as  it  does 
sometimes  in  the  Adirondacks.  The  cold  wind 
is  sure  to  blow  down  one's  back.  This  may  be 
overcome  by  arranging  the  pillows  in  the  form 
of  a  V,  w^ith  the  apex  at  the  head  and  the  other 
ends  reaching  under  the  clothing. 

Some  patients  complain  that  the  bright  light 
awakens  them  too  early  in  the  morning,  and  that 
they  have  difficulty  in  going  to  sleep  again.  In 
such  instances  they  may  place  a  piece  of  some 
light  weight  but  dark  colored  material  (such  as  a 
black  lisle-thread  hose)  over  the  eyes.  This  usu- 
ally suffices  to  obviate  the  inconvenience  caused 
by  the  bright  light. 

The  pulmonary  invalid  when  in  bed  should 
be  provided  with  a  bell  to  communicate  with  his 
nurse,  relatives,  or  friends  who  take  care  of  him. 
He  should,  of  course,  have  a  small  sputum  cup 
or  pocket  flask  handy  to  receive  his  expectoration. 
I  prefer  the  flask  for  use  in  the  window-tent, 
for  it  seems  to  me  that  any  kind  of  cuspidor 
which  had  to  stand  on  the  window-sill  would  not 
be  as  safe,  as  there  is  always  a  danger  of  its  falling. 


OPEN  AIR  TREATMENT  79 

A  urinal  should  also  be  placed  at  the  bedside,  so 
that  the  patient  will  not  have  to  leave  the  bed  in 
the  night  and  be  uselessly  chilled. 

When  arranging  for  the  rest-cure  in  the  re- 
clining chair  during  the  day,  whether  it  is  in  the 
half  tent,  in  the  garden,  on  the  veranda,  in  the 
sleeping  shack,  on  the  roof,  or  on  a  balcony,  one 
should  always  bear  in  mind  that  it  is  much  more 
agreeable  and  conducive  to  the  well-being  of  the 
patient  to  have  a  pleasant  view  to  look  upon. 
In  building  sanatoria  the  greatest  attention  is  paid 
to  the  proper  selection  of  the  place  for  the  rest- 
cure  gallery  or  veranda.  The  more  pleasing  and 
entertaining  the  outlook  from  these  places,  the 
more  certain  one  is  to  keep  the  patients  quiet  and 
restful. 

Where  the  choice  of  a  place  is  limited,  one  will 
have  to  do  the  best  he  can.  If  there  is  no  garden, 
veranda,  porch,  or  flat  roof  that  the  patient  may 
use,  the  window-tent  can  be  put  into  service  also 
for  the  rest-cure  during  the  day.  The  bed  is  moved 
away  and  the  reclining  chair  is  put  in  its  place. 
The  latter  can  be  raised  to  the  necessary  height 
by  wooden  blocks  or  a  platform,  and  with  the  aid 
of  blankets  and  comforters  the  air  from  the  room 
can  be  excluded  and  the  patient  in  front  of  the 
open  window  will  breathe  only  outdoor  air. 

Sometimes  the  patient  is  so  poor  or  so  situated 


8o  TUBERCULOSIS 

that  the  purchase  of  an  aerarium  or  window-tent 
is  out  of  question.  Or,  again,  a  suitable  outdoor 
or  indoor  arrangement  for  the  fresh  air  cure  can  not 
be  made  at  once.  What,  then,  is  the  patient  to  do  ? 
He  should  move  his  bed  as  near  as  possible  to 
the  window  and  open  the  lower  sash  almost  as 
wide  as  it  will  go,  lowering  the  upper  one  a  few 
inches  from  the  top.  If  he  finds  that  there  is  a 
draught,  that  the  direct  air  in  his  face  is  too 
much,  or  if  he  does  not  wish  to  be  seen  by  his 
neighbors,  he  can  obviate  all  these  difficulties 
by  moving  the  bed  about  one  or  two  feet  from 
the  window  and  placing  a  screen  between  the 
window  and  himself.  To  avoid  draught  he  need 
not  raise  the  windoAV  above  the  height  of  the 
screen.  An  even  simpler  device  is  a  sheet  tacked 
to  the  window- frame  and  drawn  out  over  the  bed 
to  serve  as  an  improvised-window  tent. 

When  beginning  the  aerotherapy,  or  open  air 
treatment,  it  is  essential  to  do  it  gradually  and 
according  to  the  susceptibility  of  the  patient  to 
cold.  The  fact  should  be  impressed  upon  him 
that  night  air  is  as  pure  as  day  air.  If  the  treat- 
ment is  started  in  midwinter,  one  should  select 
the  milder  days  for  the  beginning  of  outdoor 
sleeping  or  outdoor  resting  and  start  with  a  few 
hours  at  a  time.  A  hot  water -bag  or  hot  soap- 
stone  for  the  feet,  either  in  bed  or  in  the  chair, 


USE  OF  COLD  WATER  8i 

may  often  be  necessary  in  extremely  cold  weather. 
The  patient's  feet  must  be  kept  warm  if  he  is  to 
benefit  from  the  open  air  treatment. 

There  is  no  reason  why  hydrotherapy,  that  is 
to  say,  the  use  of  cold  water  as  a  curative  agent, 
should  not  be  employed  in  the  home  as  well  as  in 
the  sanatorium.  It  is  a  most  valuable  tonic  and 
serves  to  prevent  the  patient  from  contracting 
colds,  which  are  always  apt  to  give  him  a  set-back 
in  the  cure. 

The  physician  will  direct  the  hydrotherapy  as 
well  as  the  open  air  treatment.  He  will  get  his 
patient  accustomed  to  the  use  of  cold  water  by 
degrees.  He  will  begin  with  a  friction  of  the 
whole  body  with  pure  alcohol  once  or  twice  a  day, 
for  a  number  of  days.  This  is  followed  by  friction 
with  half  alcohol  and  half  water,  then  for  the 
same  length  of  time  with  water  alone;  thus  we 
come  gradually  to  douches  of  cold  water,  which 
should  be  taken  first  with  a  temperature  of  60° 
and  gradually  decreased  to  40°  F. 

The  physician  will  instruct  his  patient  that  a 
chilly  sensation  after  the  bath  is  a  sign  that  he 
has  not  reacted  well  and  that  then  the  water  must 
be  more  carefully  tempered.  Individualizing  is 
most  important  in  hydrotherapy  for  the  tubercu- 
lous, and  the  use  of  cold  douches  or  shower  baths 
should  not  be  resorted  to  without  the  special  advice 


^2  TUBERCULOSIS 

of  the  physician.  Children  and  the  aged  do  not 
react  as  well  as  the  adult  or  middle-aged,  and  in 
cold  weather  douches  should  never  be  given  in 
cold  rooms. 

No  elaborate  hydrotherapeutic  appliances  are 
necessary  in  order  to  give  a  douche.  In  the  families 
of  the  poor  the  luxury  of  the  douche  apparatus 
is  unknown,  and  often  they  have  not  even  a  bath- 
room. In  such  instances  I  give  the  following 
advice:  Procure  a  circular  English  bathtub,  about 
three  feet  in  diameter  and  ten  inches  high,  and 
pour  about  five  inches  of  cold  or  tepid  water  into 
it.  The  bather  jumps  into  the  water,  keeping  his 
feet  in  motion  for  a  few  seconds,  then  a  second 
person  pours  quickly  one  or  two  pitcherfuls  of 
water  over  each  shoulder,  thoroughly  wetting  the 
whole  body.  It  is  best  to  keep  the  head  dry. 
The  patient  might  be  able  to  pour  the  water  on 
himself,  but  the  help  of  a  second  person  will  much 
facilitate  the  operation.  If  a  hose  can  be  attached 
to  a  near-by  faucet,  a  douche,  bath,  or  direct  jet 
can  be  improvised.  If  the  ambulant  patient  is 
obliged  to  attend  to  the  douche  himself,  he  should 
place  a  large  empty  washbowl  or  a  small  tub  near 
the  bed  on  the  floor  to  stand  in,  and  have  a  smaller 
washbowl  filled  with  cold  water  placed  at  the 
height  of  the  table  with  a  good  sized  sponge. 
He  may  go  to  bed  first  and  get  thoroughly  warm. 


USE  OF  COLD  WATER  83 

then  rise,  remove  his  night  clothes  and  take  his 
douche  by  standing  in  the  larger  bowl  and  squeez- 
ing out  the  sponge  soaked  in  the  cold  water  in  the 
smaller  basin  once  over  his  left  shoulder,  once 
over  his  right,  once  in  front  of  the  neck,  and  once 
over  the  back  of  the  neck.  Thus, the  whole  body 
will  be  douched.  He  should  dry  himself  quickly, 
and  if  he  feels  chilly  he  can  return  to  the  warm 
bed.  Unless  the  patient  has  been  in  the  habit  of 
using  cold  water  and  his  reaction  is  perfect,  that 
is  to  say,  unless  he  experiences  quickly  a  pleasant 
warm  sensation  after  the  application  of  cold  water, 
the  precaution  just  described  of  going  first  to  bed 
to  get  warm  and  using  warm  water  in  the  big  tub 
to  stand  in,  is  to  be  strongly  recommended. 


CHAPTER  V 

HOW  SANITATION  AND  PROPER  HOUSING  MAY  HELP 
TOWARD  THE  PREVENTION  OF  TUBERCULOSIS 

Hygiene  and  sanitation  stand  for  the  preven- 
tion of  diseases,  and  in  regard  to  tuberculosis  it 
is  our  duty  to  trace  the  primary  predisposing 
causes  as  well. as  the  direct  causes,  and  prevent 
them  as  far  as  lies  in  our  power.  One  of  the  most 
important  primary  predisposing  causes  of  tuber- 
culosis is  to  be  found  in  foul  air  due  to  unsanitary 
housing,  overcrowding,  and  the  narrow  streets  in 
cities  which  do  not  permit  sufficient  light  and  air 
to  enter  into  the  living  apartments,  shops,  or  fac- 
tories situated  on  them. 

It  is  doubtlessly  in  the  polluted  condition  of  the 
atmosphere  that  we  must  look  for  one  of  the 
causes  of  the  great  mortality  from  tuberculosis  in 
large  centers  of  population  and  in  manufactur- 
ing districts.  In  our  large  cities,  particularly 
in  the  lower  strata  of  air  where  there  is  less  dif- 
fusion of  gases,  complete  change  only  takes 
place  when  it  is  sufficiently  windy,  and  when  the 

streets  are  wide  enough  and  not  lined  by  a  row  of 

84 


POLLUTED  AIR  IN  LARGE  CITIES  85 

houses  so  high  that  there  is  almost  no  sunhght  in 
them. 

The  diffusion  of  the  gases  of  the  air  is,  of  course, 
still  more  limited  in  a  closed  room,  and  a  change 
of  air  is  impossible.  The  more  individuals  that 
occupy  a  limited  inclosed  space,  the  sooner  will 
the  air  be  unfit  for  human  beings  to  breathe.  At 
one  time  it  was  supposed  that  the  diminution  of 
oxygen  and  the  increase  of  carbonic  acid  in  an 
atmosphere  vitiated  by  respiration  were  the  chief 
causes  of  its  noxious  effect  on  the  persons  breath- 
ing it.  The  experiments  of  recent  investigators, 
however,  have  thrown  considerable  doubt  on  that 
explanation. 

The  amount  of  carbonic  acid  ordinarily  in  the 
air,  is  from  3  to  4  parts  in  every  10,000,  and  the 
presence  of  this  quantity  will  not  be  perceived  by 
the  normal  human  organism.  Even  as  large  a 
proportion  as  i  per  cent  can  be  borne  for  some 
time  without  giving  rise  to  disturbance;  and  air 
containing  as  much  as  4  per  cent  has  been  breathed 
for  ten  minutes  without  harm  (Huggard). 

Carbonic  acid  owes  its  evil  reputation  chiefly, 
not  to  its  own  bad  qualities,  but  to  its  bad 
company.  Where  the  atmosphere  of  a  room  has 
been  vitiated  by  respiration  to  such  a  degree  that 
the  amount  of  carbonic  acid  is  3  per  1,000,  the 
air  is  distinctly  unfit  for  breathing.     The  sub- 


86  TUBERCULOSIS 

stances  that  cause  the  deterioration  are  unknown; 
but  in  such  circumstances  the  carbonic  acid  serves 
as  a  measure  of  their  amount.  Air  containing 
from  30  to  40  per  cent  of  carbonic  acid  proves 
immediately  fatal  when  a  person  enters  it  from 
the  fresh  air.  The  symptoms  of  poisoning  from 
smaller  quantities  are  generally  paralysis  and  loss 
of  consciousness.  Carbonic  acid  gas  exists  in  the 
blood  chiefly  in  chemical  combination  with  the 
salts  of  soda  and  with  the  haemoglobin.  The 
portion  united  with  the  haemoglobin  is  displaced 
by  oxygen  at  each  inspiration. 

Pure  air  strengthens  and  invigorates  the  body 
and  increases  the  resisting  power  to  disease;  but 
it  is  most  remarkable  how  the  human  system  will, 
to  a  very  large  extent,  become  insensible  to  the 
fact  that  it  is  gradually  being  starved  for  w^ant 
of  a  sufficient  amount  of  pure  air  and  thus  poi- 
soned by  the  various  noxious  by-products  of  res- 
piration. Some  one  has  described  breathed  air 
which  is  saturated  with  respiratory  impurities 
as  containing  air  sewage.  As  has  been  said,  it 
does  not  seem  to  be  so  much  the  excess  of  car- 
bonic acid  as  the  additional  by-products  of  ex- 
pired air — vapors  charged  with  toxic  substances— 
which  undermine  the  health.  It  would  seem  that 
when  the  human  system  reabsorbs  the  poisons 
exhaled  from  a  pulmonary  surface,  by  breathing 


EFFECT  OF  PURE  AIR  87 

the  air  already  breathed,  a  particularly  suitable 
field  of  growth  of  the  bacilli  of  tuberculosis  is 
created. 

In  my  labors  among  the  poor  of  the  tenement 
house  districts  in  large  cities  I  have  often  been 
amazed  to  see  that  people  could  live  in  an  atmos- 
phere which  was  so  evidently  vitiated  and  poison- 
ous. The  result  of  living  under  such  conditions, 
be  they  produced  in  the  home  of  the  poor  or  the 
well-to-do,  in  factory  or  workshop,  by  ignorance 
or  greed,  is  a  diminished  desire  for  deep,  natural 
breathing;  the  respiratory  centers  become  dulled 
by  the  excess  of  carbonic  acid  and  the  poisonous 
by-products  of  respiration  in  the  atmosphere.  The 
respiratory  capacity  of  the  lungs  becomes  more  and 
more  diminished  and  the  individual  receives  only 
just  enough  oxygen  to  sustain  life.  A  truly  physi- 
ological haematosis,  that  is  to  say,  a  full  physiolog- 
ical exchange  of  arterial  (oxygenated)  for  venous 
blood  in  the  lungs  takes  place  but  rarely.  The 
thoracic  or  respiratory  muscles  in  the  chest,  being 
little  used,  become  atrophied  (thinned  and  weak- 
ened), the  individual  assumes  a  stooping  attitude 
and  before  he  realizes  it  himself  he  has  acquired 
the  typical  hahitiis  phthisicns,  that  is  to  say,  a 
narrow  chest,  stooping  shoulders,  and  a  pale  and 
emaciated  appearance.  If  such  an  individual 
should  be  exposed  to  the  inhalation  of  the  tubercle 


88  TUBERCULOSIS 

bacilli  in  the  form  of  tuberculous  dust,  should  in- 
gest tuberculous  substance  in  the  form  of  meat  or 
milk  from  tuberculous  cattle,  should  be  accident- 
ally inoculated  with  tuberculous  matter  through  a 
scratch  or  ^YOund,  or  be  in  close  contact  with  a 
careless  tuberculous  patient,  he  is  most  liable  to  be- 
come infected. 

The  lower  strata  of  the  air  in  many  city  streets 
are  very  little  stirred  up  by  the  winds  passing  over 
them,  and  this  is  all  the  more  the  case  when  the 
city  is  built  in  a  valley. 

In  a  country  like  the  United  States  where  the 
founding  of  new  cities  is  nothing  unusual,  the 
builders  of  the  future  should  bear  in  mind  that 
a  city  situated  on  high  ground  with  wide  streets 
will  be  a  healthy  city  and  relatively  free  from 
tuberculosis.  In  existing  cities  the  widening  of 
streets  and  the  lowering  of  too  high  buildings  will 
help  the  freer  circulation  of  air,  and  the  admit- 
tance of  sunlight  will  very  materially  improve  the 
sanitary  condition. 

The  city  of  Chicago  is  one  of  the  healthiest 
cities  in  the  United  States,  and  while  I  gladly  pay 
homage  to  the  men  at  the  head  of  its  excellent 
sanitary  supervision,  there  is  no  doubt  in  my  mind 
that  the  wind  to  which  the  city  is  so  much  exposed 
is  in  no  small  degree  responsible  for  its  healthy 
condition, 


EFFECT  OF  PURE  AIR  89 

Another  important  matter,  which  has  a  vital 
relation  to  tuberculosis  and,  in  fact,  to  all  diseases 
of  the  respiratory  organs,  should  be  taken  into 
consideration  by  the  builders  of  new  cities.  When 
it  is  possible,  a  city  should  be  located  near  a 
wooded  region,  and  the  wanton  destruction  of  the 
trees  should  never  be  allowed.  Climate  and  at- 
mosphere will  always  be  more  favorable,  and 
diseases  like  tuberculosis,  bronchitis,  and  pneu- 
monia will  be  relatively  rarer  in  wooded  districts. 

To  give  plenty  of  sunlight  and  air  to  the  indoor 
workers  of  the  city,  houses  should  not  be  built 
higher  than  the  wndth  of  the  street.  The  greatest 
angle  of  direct  light  from  the  sky  for  the  first 
floor  should  be  45°.  The  streets  in  all  our  cities 
should  be  laid  out  wide  enough  to  permit  the 
planting  of  trees  on  both  sides,  and  the  necessity 
for  plenty  of  small  parks  and  playgrounds  should 
be  borne  in  mind  if  the  city  is  expected  to  have  a 
low  mortality  from  tuberculosis. 

Of  factory  and  workshop  hygiene  we  will  speak 
later  on.  Here  we  desire  to  show  the  importance 
of  fresh  and  good  air  indoors  because  of  its  value 
as  a  preventive  in  tuberculosis. 

All  civilized  men  spend  one-third  of  their  lives 
indoors  for  sleep,  and  of  all  workers  in  the  various 
fields  of  human  activity  by  far  the  greater  number 
have  indoor  occupations.    According  to  the  United 


go  TUBERCULOSIS 

States  census  of  1900,  there  were  29,073,233  per- 
sons over  ten  years  of  age  engaged  in  earning 
their  livehhood  in  some  one  of  303  specified  occu- 
pations, out  of  which  only  46  could  be  strictly 
called  outdoor  occupations.  The  total  number 
engaged  in  these  latter  were  12,058,671.  The 
number  engaged  in  the  257  indoor  occupations 
would  thus  be  17,014,562.  If  we  add  to  this  the 
time  all  classes  of  people  spend  indoors  for  eating, 
for  resting,  for  amusement,  instruction  or  worship, 
well  may  we  say  that  the  greater  part  of  the  people 
of  the  United  States  virtually  spend  their  lives 
indoors. 

In  order  that  the  houses  where  people  live 
should  assure  the  individual  the  greatest  possible 
amount  of  security  against  disease,  particularly 
against  tuberculosis,  all  human  habitations,  as 
far  as  practicable,  should  be  built  on  good  porous 
soil,  preferably  coarse  sand  or  gravel;  the  next 
best  is  rock,  and  only  third  in  order  comes  clay. 

Private  houses,  whether  occupied  by  one  or 
two  families,  whether  in  the  city  or  country, 
should  be  built  so  that  there  will  be  no  dark 
rooms.  All  the  living  rooms  should  have  southern 
exposure,  even  at  the  risk  of  having  the  kitchen 
and  the  rarely  frequented  parlor  facing  north. 

In  the  absence  of  public  playgrounds  in  large 
towns   or   cities^  house-owners,  either  by  single 


CONSTRUCTION  OF  PRIVATE  HOUSES      91 

endeavor  or  by  combining  with  their  immediate 
neighbors,  might  provide  a  private  playground 
for  the  children.  If  this  is  not  feasible,  the  roof 
of  the  house,  with  the  aid  of  strong  wire  netting, 
should  be  transformed  into  a  safe  roof-garden  and 
serve  as  a  play  place  for  the  children.  The  ac- 
companying picture  (Fig.  27)  shows  how  the  roof 
of  an  ordinary  city  house  can  be  made  into  an 
attractive  playground  for  children.^  In  building 
individual  private  homes  the  sanitation  often 
suffers  from  the  desire  for  too  many  rooms;  there 
must  be  a  certain  number,  no  matter  how  small, 
and  usually  they  become  badly  lighted  and  ven- 
tilated on  that  account. 

I  consider  our  American  windows,  of  which 
only  one-half  can  be  opened,  inferior  to  the  French 
casement  window^s  which  allow  twice  the  amount  of 
bad  air  to  escape  and  good  air  to  come  in. 

In  the  construction  of  even  the  better  class 
hotels  and  apartment  houses  in  which  so  many 
American  families  now  make  their  homes,  the 
same  criticism  of  small  rooms  and  the  absence  of 
a  playground  for  children  may  be  made.  In 
building  hotels  and  apartment  houses,  I  consider 
it  well-nigh  criminal  to  raise  them  to  such  a  height 
that  the  houses  opposite  or  on  the  side  are  deprived 

1  There  would  be  fewer  children  killed  or  injured  by  street  vehicles 
if  playgrounds  were  provided  for  them  on  the  roofs. 


92 


TUBERCULOSIS 


Fig.  27.     Children  at  Play  on  the  Roof  of  a  Private  House  in  New 

York  City. 

of  sunshine  and  light  the  greater  part  of  the  day. 
It  would  seem  that  a  law  limiting  the  height  of 
buildings,  particularly  in  the  residential  section 
of  our  American  cities,  is  an  urgent  necessity. 

The  problem  of  housing  our  lal^oring  popula- 
tion in  large  cities  where,  owing  to  lack  of  transit 


GARDEN  CITIES  93 

facilities,  the  masses  must  remain  near  their  places 
of  work,  has  baffled  the  minds  of  our  philan- 
thropists, city  authorities,  and  sanitarians.  The 
congestion  in  some  cities  is  something  fearful  to 
contemplate.  This  is  particularly  true  of  the  city 
of  New  York,  in  some  sections  of  which  there  are 
more  people  to  the  square  mile  than  in  either  Lon- 
don, Paris,  or  Berlin.  Our  only  salvation  from  this 
fearful  situation,  not  only  for  New  York  but  for 
many  other  American  cities,  lies  on  one  hand  in 
good  and  extensive  rapid  transit  facilities,  con- 
comitant with  the  building  of  sanitary  homes  for 
the  laboring  masses  where  they  can  have  comfort 
and  home  life  at  reasonable  rentals;  and  on  the 
other,  in  the  building  of  model  tenements  in  the 
cities. 

There  is  a  third  way  of  solving  this  problem 
which  is  known  as  the  Garden  City  movement. 
It  originated  in  England,  and  has  already  found 
its  imitators  in  the  United  States  in  what  is  known 
as  the  Garden  Cities  Association  of  America. 
Briefly  stated,  the  aim  of  this  splendid  humani- 
tarian movement  is  the  founding  and  development 
in  the  country  of  industrial  garden  cities,  in  which, 
amid  beautiful  and  healthful  surroundings,  fac- 
tories, stores,  or  other  forms  of  business  may  be 
established;  and  where  the  workers  may  have  at- 
tractive, though  inexpensive  homes,  well  ventilated 


94  TUBERCULOSIS 

and  lighted,  each  with  its  own  garden,  and  all  to 
combine  as  many  as  possible  of  the  attractions 
both  of  city  and  of  country. 

The  Garden  City  Association  of  Great  Britain 
is  now  building  its  first  garden  city  at  Letch- 
worth,  Hertfordshire,  England. 

It  will  be  some  time,  however,  before  such 
movements  can  benefit  the  majority  of  workers, 
and  we  must  consider  the  tenement  houses  as  they 
will  have  to  be  erected  in  many  cities.  Ideal 
tenement  houses  were  planned  for  the  New  York 
Tenement  House  Exhibition,  and  I  give  a  repro- 
duction of  the  one  by  Mr.  R.  Thomas  Short,  to 
which  the  prize  was  awarded  in  a  competition  of 
175  architects.  (Fig.  28.)  I  consider  the  model 
tenement  house  such  an  important  feature  in 
the  prevention  of  tuberculosis  that  I  feel  it  my 
duty  to  speak  of  this  excellent  plan  somewhat 
in  detail.  It  is  designed  for  a  tenement  house 
on  a  lot  100  feet  wide  by  100  feet  deep.  A  space 
10  feet  in  width  and  100  feet  in  length  is  left 
at  the  rear  of  the  building  for  light  and  air,  as 
required  by  the  New  York  Building  Laws.  The 
main  feature  of  the  plan  is  the  large  street  court, 
which  in  its  narrowest  part  is  12  feet  wide  and 
one-half  of  which  is  24  feet  wide.  This  court 
is  60  feet  in  total  depth,  and  provides  an  abund- 
ance of  light  and  air  for  all  the  rooms.     Being 


MODEL  TENEMENT  HOUSES 


95 


USHT  AND  AUt  irACt 

3«V,)t 

CLEAR  RENTAIU  AUA 

ABOUT  fO  % 
U  APABTMEXTt 
■10  FRONT  APAfmiEim 

44  R00M5  3t  cLoaers 
private  hall'  to  lach 
apartuent 

m'section  of  TWI* 
plan  conforiit  to  all 

THE  REQUIREUEKTI  tf 
CLASH 


Fig.   28.     R.   Thomas  Short's  Prize  Plan  for  a  Model  Tenement 

House. 

open  to  the  street,  it  permits  free  circulation  of 
air  at  all  times,  and  has  the  additional  advantage 
of  giving  a  number  of  rooms  an  outlook  upon  the 
street,  thus  creating  a  greater  number  of  "front 
apartments,"  and  materially  increasing  the  rental 
values  of  the  building.  The  plan  provides  ac- 
commodations for  fourteen  families  on  a  floor, 
having  a  total  of  forty- four  rooms,  and  an  abund- 
ance of  closets.  The  lack  of  closet  space  has  been 
one  of  the  serious  inconveniences  of  tenement 
house  life.     Besides  this,  the  plan  possesses  the 


96  TUBERCULOSIS 

further  advantage  of  having  a  private  hall  for 
every  set  of  rooms,  thus  insuring  privacy  to  the 
tenants.  Every  family  has  its  own  water-closet 
entirely  within  its  control.  There  is  no  part  of 
the  building  more  than  two  rooms  deep.  This  is 
the  secret  of  the  whole  tenement-house  problem, 
because  it  means  that  there  are  no  dark  interior 
rooms.  Besides  these  many  advantages,  there 
are  four  light  staircases  and  staircase  halls  pro- 
vided for  the  tenants,  thus  securing  greater  safety 
in  case  of  fire,  and  removing  to  a  large  extent  much 
of  the  social  friction  that  exists  in  the  ordinary 
tenement  house.  A  large  open  court  also  provides 
a  natural  playground  for  the  children,  and  does 
away  with  the  necessity  of  subjecting  them  to  the 
influence  of  the  street. 

This  plan  is  most  excellent,  but  it  does  not 
quite  realize  my  idea  of  what  a  model  tenement 
house  in  our  large  cities  should  be,  which  is  de- 
signed to  help  solve  the  tuberculosis  problem. 
From  what  has  been  said  in  the  preceding  chap- 
ter, it  must  ])e  clear  to  the  reader  that  fresh  air 
flay  and  night  is  the  best  preventative  and  also 
one  of  the  most  important  curative  factors  in 
tuberculosis.  As  we  have  seen,  sleeping  outdoors, 
weather  permitting,  is  particularly  useful  in  the 
treatment  of  tuberculosis,  and  it  is  of  equal  value 
in  the  prevention  of  the  disease.     I  am  sure  that 


o 
B 


o 


O 


c 
.2 

> 


98  TUBERCULOSIS 

if  the  tenement  house  population  of  any  large  city 
would  be  convinced  of  this  and,  at  the  same  time, 
facilities  provided  for  them  to  sleep  in  the  open 
air,  tuberculosis  would  soon  be  eradicated  among 
the  masses. 

A  problem  which  I  have  longed  to  solve  for 
years  has  been  how  to  build  tenement  houses 
where,  if  all  the  inmates  could  not  have  balconies 
to  sleep  on,  at  least  those  might  who  would  be 
greatly  benefited  thereby,  whether  because  they 
were  predisposed  or  actually  tuberculous,  or  were 
convalescent  from  some  other  disease.  On  this 
subject  I  have  consulted  many  times  with  my 
friend  and  fellow  student.  Professor  John  Van  Pelt 
of  the  School  of  Architecture  of  Columbia  Uni- 
versity. It  is  thanks  to  his  cooperation  that  I  am 
able  to  present  drawings  and  descriptions  of  such 
an  open  air  tenement  house  in  this  little  volume. 

As  the  name  indicates,  this  building  (Fig.  29) 
is  primarily  designed  to  give  plenty  o£  light  and 
air  to  each  room  and  apartment,  thereby  assur- 
ing ventilation  which  can  not  be  secured  in  the 
ordinary  tenement.  Furthermore,  balconies  are 
provided  on  which  a  number  of  the  inmates  may 
sleep  in  the  open  air. 

The  plan  (Fig.  30)  is  so  arranged  that  there 
will  be  large  courts  opening  out  upon  the  street 
insuring  light  at  all  hours  of  the  day.     These 


O 


loo  TUBERCULOSIS 

courts  are  37'  wide  and  60'  long.  It  is  especially 
important  that  these  courts  open  to  the  south, 
that  the  sun  may  penetrate  to  the  rear  of  the 
court  and  dry  both  sides.  It  is  also  important 
that  the  interrelation  between  the  height  of  the 
building,  the  depth  of  the  court  and  its  width  be 
so  proportioned  that  the  lower  floor  and  rear  of 
the  court  shall  receive  several  hours  sunlight  dur- 
ing the  day. 

In  order  to  stimulate  the  movement  of  the  air 
currents,  it  is  important  that  the  enclosure  on  the 
street  side  be  as  open  and  as  low  as  possible.  The 
present  design  shows  a  simple  iron  fence. 

Moreover,  the  ground  has  been  inclined  up 
from  the  street  so  that  moisture  will  tend  to  drain 
to  the  front  of  the  court  and  not  remain  in  a  damp 
pocket  at  the  back,  and  so  that  the  colder,  more 
impure,  and  heavier  air  of  the  court,  tending  to 
fall,  will  move  toward  the  street  and  be  replaced 
by  fresher  air  coming  from  above.  A  grade  of 
-^  inch  to  the  foot  or  5  per  cent  would  not  be  too 
high  for  other  practical  purposes  and  would  be 
useful  from  this  point  of  view. 

The  building  is  divided  into  nineteen  apart- 
ments on  each  floor.  These  apartments  consist  of 
two,  three,  four,  and  five  rooms.  The  five-room 
apartments  are  the  only  ones  that  have  a  parlor. 
The  others  have  living  room  and  bedrooms. 


MODEL  TENEMENT  HOUSES  lot 

All  the  apartments  have  some  rooms  on  the 
sunny  side.  Each  apartment  has  either  a  balcony 
or  a  recessed  loggia;  those  upon  the  street  being 
protected  from  view  by  an  open-work  screen  with 
a  space  between  the  bottom  of  the  screen  and  the 
floor,  leaving  the  top  open.  This  gives  perfect 
circulation  of  air,  yet  would  make  them  service- 
able for  sleeping. 

The  balconies  are  not  run  across  the  whole  face 
of  the  wall  so  as  not  to  cause  any  useless  shade, 
and  to  allow  as  much  light  as  possible  to  enter  the 
windows  of  the  rooms  which  are  without  balco- 
nies. The  balconies  are  provided  with  open-work 
screens  on  either  side,  these  being  so  installed 
that  they  can  be  folded  back  against  the  house 
like  shutters  during  the  daytime  and  in  fine 
weather.  When  opened,  they  give  privacy  and 
some  protection  from  severe  winds.  These  screens 
might  be  advantageously  fitted  with  louvres  which 
could  be  closed. 

French  casement  windows  are  used  throughout 
the  building,  the  whole  window  space  opening  to 
permit  the  maximum  of  fresh  air  and  sunlight  to 
enter. 

The  stairways  and  stairway  hall  are  also  very 
open.  They  are  reached  directly  from  the  large 
courts  and  eliminate  the  dark,  dreary  stairways  of 
the  ordinary  tenement. 


I02  TUBERCULOSIS 

Since  an  elevator  would  considerably  increase 
the  cost  and  maintenance  of  the  building,  a  com- 
fortable settee  is  installed  at  the  end  of  each  stair- 
case to  give  the  pulmonary  invalid  a  chance  to 
rest  before  mounting  another  flight. 

Toilets  are  so  placed  that  they  will  have  ample 
ventilation  and  their  quota  of  sunlight.  They  are 
kept  free  of  the  balconies. 

It  is  probable  that  such  a  building  would  be  of 
the  semifireproof  type.  A  fireproof  construction 
is,  however,  far  more  advisable  in  that  it  affords 
less  facility  for  the  passage  of  vermin  from  one 
point  to  another.  On  account  of  the  nature  of  the 
problem,  it  is  evident  that  the  expense  in  con- 
struction must  be  greater  proportionately  than 
that  of  the  ordinary  tenement,  but  such  an  in- 
crease can  be  kept  within  bounds  and  yet  permit 
a  high  degree  of  efficiency  in  the  sanitary  condi- 
tions which  will  be  afforded. 

The  courts,  on  account  of  their  size  and  open- 
ness, afford  space  for  the  children  to  play  in, 
keeping  them  off  the  street.  Besides  this,  a  roof 
garden  is  provided  which  can  be  made  use  of 
during  the  day  and  night.  Separate  water-closets 
for  men  and  women  are  provided  on  the  roof. 
The  design  shows  plants  which  might  be  main- 
tained in  boxes  on  the  roofs,  the  verdure  serving 
to  make  the  outlook  more  attractive. 


MODEL  TENEMENT  HOUSES  103 

It  will  probably  be  a  long  time  before  all  the 
tenement  houses  in  our  large  cities  will  have 
balconies  for  outdoor  sleeping  and  such  well 
ventilated  bedrooms  as  to  assure  the  greatest  pos- 
sible amount  of  pure  air  to  those  sleeping  indoors ; 
but  can  not  something  be  done  in  the  meantime 
to  utilize  the  hundreds  of  acres  of  space  repre- 
sented by  the  fiat  roofs  of  a  large  city,  such,  for 
example,  as  New  York?  The  hospitals  in  our 
large  cities,  whose  ground  space  is  necessarily 
limited,  have  already  realized  the  inestimable 
value  of  the  roofs  for  the  open  air  cure  of  diseases 
of  all  kinds,  not  only  tuberculosis.  The  accom- 
panying picture  (Fig.  31)  shows  a  group  of  happy 
children,  several  of  them  operated  on  for  surgical 
tuberculosis,  on  the  roof  of  the  New  York  Post- 
Graduate  Medical  School  and  Hospital.  The 
Presbyterian  Hospital  treats  its  pneumonic  chil- 
dren on  the  roof  even  in  midwinter. 

On  page  92,  Fig.  27,  we  showed  a  picture  of 
the  roof  of  a  private  house  transformed  into  a 
playground.  What  a  boon  it  would  be  to  many 
a  tenement  dweller,  and  even  to  those  dwell- 
ing in  private  homes  and  apartments,  if  dur- 
ing the  sweltering  heat  of  our  summer  nights 
comfortable  sleeping  quarters  could  be  provided 
for  them  on  the  roofs!  I  am  indebted  to  INIr. 
Frederick  D.  Greene  for  the  accompanying  inter- 


ROOF  CAMPING  AND  PLAY  GROUNDS 


105 


Fig.  32.     Roof  Camping  in  Midsummer  in  New  York. 

esting  picture  illustrating  what  he  calls  ''roof- 
camping"  in  New  York  City  (Fig.  32);  and  what 
he  says  in  his  interesting  article,  "The  Roofs  of 
New  York,"  which  appeared  in  ''Charities  and 
the  Commons,"  (now  "The  Survey")  of  August 
15,  1908,  may  guide  us  in  the  better  utilization  of 
our  housetops : 

"The  fact  that  New  York  roofs  would  not  accommo- 
date all  who  have  been  allowed  by  social  negligence  to 
herd  under  them  to  a  degree  that  no  intelligent  breeder 
of  hens  or  cattle  would  permit,  is  no  reason  why  we 
should  not  at  once  turn  to  the  roofs  for  the  relief  from 
night  discomfort  and  congestion  that  they  can  afford  to 
large  numbers, 


io6  TUBERCULOSIS 

"Of  course,  there  are  difficulties  to  be  surmounted 
under  present  conditions  by  those  who  would  sleep  on 
the  roof.  In  many  houses  and  even  tenements  the  only 
access  is  up  a  ladder  and  through  a  scuttle  two  feet 
square.  A  parapet  to  prevent  people  from  walking  or 
rolling  off  is  generally  lacking.  Points  of  attachment 
for  supporting  an  awning  or  tent  in  case  of  rain  are 
hard  to  find.  The  question  of  privacy  and  of  safety 
from  thieves  must  be  considered.  But  all  these  diffi- 
culties can  and  must  be  overcome  in  order  that  this  great 
boon — God's  fresh  air  that  blows  over  the  city  as  well 
as  over  the  country — may  be  enjoyed  to  the  full. 

"A  readily  accessible  roof  that  can  stand  wear,  and 
which  is  protected  by  a  wall  or  iron  fence,  should  be 
required  by  law  as  a  sine  qua  non  of  every  tenement 
and  apartment  house.  This  would  put  a  safe,  clean 
breathing  spot  within  the  reach  of  every  mother,  ''little 
mother,"  and  babe,  without  the  crossing  of  a  street. 

"The  roofs  of  the  cities  are  undiscovered  countries. 
In  spite  of  incredulous  smiles  and  friendly  warnings 
the  writer  has  been  forming  a  delightful  acquaintance 
with  this  country  for  some  weeks." 

Many  of  the  roofs  of  the  now  existing  tenement 
and  apartment  houses  could  be  transformed,  v^ith 
relatively  little  expense,  into  secure  playgrounds  for 
children  and  decent  and  respectable  sleeping  ac- 
commodations for  a  goodly  number,  at  least  in  the 
summer. 

In  cities  and  towns  where  land  is  relatively 


OPEN  AIR  PRIVATE  DWELLING  107 

cheap  and  many  individuals  own  and  build  their 
own  houses,  the  construction  can  easily  be  such 
that  not  only  are  there  no  dark  and  sunless  bed- 
rooms, but  that  any  one  of  the  members  of  a 
family  can,  if  he  wishes  to  accustom  himself  to  it, 
enjoy  the  luxury  of  outdoor  sleeping. 

To  plan  for  the  construction  of  the  open  air 
private  dwelling  as  well  as  for  the  open  air  tene- 
ment house  already  described,  I  consulted  with 
Professor  Van  Pelt,  who  has  devised  a  feasible 
way  to  construct  such  an  ideal  dwelling.  The 
following  is  the  plan  and  technical  description  of 
it  which  Mr.  Van  Pelt  has  been  good  enough  to 
work  out  at  my  suggestion : 

The  residence  shown  in  the  accompanying  pic- 
ture and  plans  (Figs.  33,  34,  35)  is  designed  so  that 
it  may  have  the  best  possible  ventilation  and  sun- 
light in  all  its  parts,  to  induce  and  realize,  to  the 
greatest  extent,  the  out-of-door  life. 

The  entrance  vestibule,  necessary  for  the  middle 
of  the  winter,  is  so  planned  that  it  can  be  removed 
in  summer,  giving  direct  exit  from  the  interior. 

French  windows  are  used  wherever  possible,  per- 
mitting them  to  open  to  the  full  size  of  the  window 
space. 

Large  fireplaces  are  introduced  to  give  cheer 
and  increase  the  ventilation. 

This  particular  design  shows  the  kitchen  and 


c 
.2 

> 


Q 

'in 
i-i 


O 


O 


OPEN  AIR  PRIVATE  DWELLING 


109 


'HkM    ri  unv  PI  /\n 


Fig.  34.     First  Floor  Plan  of  Open  Air  Private  Dwelling. 

servants'  wing  entirely  separated  from  the  main 
portion  of  the  house,  which  precludes  the  dis- 
agreeable permeation  of  the  odors  of  cookery 
through  the  atmosphere  of  the  main  portion  of 
the  dwelling.  The  connecting  porch  between  the 
kitchen  and  butler's  pantry  is  roofed,  and,  in  win- 
ter, this  can  be  enclosed  at  either  end  so  as  to  pro- 
tect the  servants ;  but  the  enclosures  of  this  porch 
can  be  taken  away  when  warm  weather  not  only 
renders  such  protections  unnecessary,  but  increases 
the  invading  quality  of  kitchen  smells. 


no 


TUBERCULOSIS 


■^rMiNii  minu  PI  AfT 


Fig.  35.     Second  Floor  Plan  of  Open  Air  Private  Dwelling. 

The  refrigerator  is  so  planned  that  not  only  can 
ice  be  put  into  an  upper  compartment  or  tray 
from  the  outside,  but  a  limited  space  can  be  opened 
up  from  the  hall  to  keep  a  few  bottles  and  cigars. 

An  open  breakfast  porch  forms  an  extension  to 
the  dining  room  and  is  large  enough  to  be  used 
for  other  meals. 

The  especial  feature  of  the  house  is  the  arrange- 
ment of  the  second  floor,  where  the  four  bedrooms 
are  situated  in  the  four  corners  of  the  house,  each 
one  having  windows  on  two  3ides  to  give  cross- 


OPEN  AIR  PRIVATE  DWELLING  in 

ventilation,  and  each  having  an  exposure  which 
v^ill  permit  sunHght  to  enter  during  a  large  portion 
of  the  day.  Moreover,  these  bedrooms  are  con- 
nected either  directly  or  through  the  bathroom, 
with  out-of-door  sleeping  verandas,  where  the  in- 
mates may  sleep  winter  and  summer.  Movable 
louvres  and  screens  enclose  these  verandas  so  that 
they  can  be  protected  from  mosquitoes,  flies,  and 
excess  of  light  in  the  early  morning,  if  that  is  de- 
sirable. 

The  second  story  sitting  room  would  have 
louvres  in  the  partition  between  it  and  the  upper 
hall,  so  as  to  give  cross-ventilation  from  one  side 
of  the  house  to  the  other.  A  passage  from  the 
main  stairs  to  the  servants'  wing  gives  access  for 
the  maids. 

The  general  material  for  the  construction  of 
this  particular  house  is  frame,  and  a  Colonial 
style  has  been  adopted;  but  the  peculiar  features 
of  cross-ventilation,  wide  balconies,  porches,  and 
out-of-door  sleeping  verandas,  can  be  accom- 
phshed  in  any  style  or  building  material. 

The  problem  of  providing  cheap  but  good  in- 
dividual homes  for  our  laboring  classes  where 
land  is  reasonable,  but  in  a  region  easily  accessible 
to  their  centers  of  work,  is  a  very  important  mat- 
ter. To  see  how  reasonably  such  a  home  could 
be  built,  I  consulted  again  with  Mr.  John  Van 


112 


TUBERCULOSIS 


Fig.  36.      Economical  Sanitary  House  for  One  Family. 

Pelt.  I  give  the  following  illustrations,  descrip- 
tion, and  plans  (Figs.  36,  37,  38)  which  he  worked 
out  for  this  purpose: 

The  building  has  been  planned  in  the  most 
economical  manner  possible.  A  single  chimney 
placed  in  the  middle  of  the  house  affords  a  fire- 
place and  contains  flues  from  the  heater  and 
kitchen  range. 

All  rooms,  except  the  smallest  bedroom,  have 
two  windows  in  different  walls,  insuring  cross 
ventilation  and  at  least  one  sunny  exposure. 
The  fireplace  in  the  living  room  acts  as  an  as- 
pirator for  foul  air  and  has  a   12''  by   ^2"  flue. 


JECONOMiCAL  SANITARY  HOUSE 


113 


Klhir^T    Kl|.4^hL   HAN 


Fig.  37.     First  Floor  Plan  of  Economical  Sanitary  House  for  One 

Family. 

Hot  air  heating  is  adopted  with  the  cold  air  in- 
take, bringing  air  directly  from  the  exterior,  each 
room  being  provided  with  a  riser,  conducting  this 
warmed  air  to  the  different  parts  of  the  house. 
The  cellar  stairs  go  down  under  the  main  stairs, 
and  a  door  leading  from  these  stairs  to  the  ex- 


114 


TUBERCULOSIS 


2E7PLSH: 


'(/w////mj^M/^^^J^^     W2^^////////,i  w/wwwvmm 


=Q — m 


Fig.  38.     Second  Floor  Plan  of  Economical  Sanitary  House  for  One 

Family. 

terior  makes  it  possible  to  carry  the  ashes,  which 
descend  to  the  ash  pit  in  the  cellar  through  a  dust 
chute  from  the  fireplace  and  those  which  also  accu- 
mulate from  the  hot  air  furnace,  directly  out  of 
doors  without  spreading  dust  through  the  house. 
The  plumbing  is  centralized,  a  single  soil  pipe 


ECONOMICAL  SANITARY  HOUSE  115 

being  sufficient,  and  the  hot  water  boiler  is  placed 
in  a  compartment  behind  the  chimney  so  as  to 
alleviate  the  conditions  that  lead  to  an  overheated 
kitchen.  The  laundry  tubs  have  been  placed  in  the 
kitchen,  as  the  wives  of  workmen  must  do  all 
their  work  and  should  be  as  near  their  family  as 
possible.  Space  has  been  provided  on  the  back 
porch  for  the  refrigerator,  a  lattice  surrounding 
the  same  to  give  shade. 

All  of  the  bedrooms  have  closets,  and  a  broom 
and  linen  closet  is  also  provided  on  the  upper 
floor. 

In  the  interior  treatment  of  the  house,  dust- 
gathering  projections  are  avoided  as  much  as 
possible.  Reentrant  corners  are  rounded,  and  a 
cove  and  sanitary  base  are  used.  The  framework 
is  stud  partition  with  rubble  or  cement  block 
foundation  wall,  according  to  locality.  A  half- 
timber  effect  is  obtained  with  stucco  in  between, 
the  house  being  sheathed  and  covered  with  build- 
ing paper  before  the  latter  is  put  on.  The  roof 
is  shingled.  The  floor  and  wainscot  of  the  large 
sleeping  balcony  of  the  second  story  are  made  of 
one  of  the  magnesite  compositions  which  have 
lately  been  used  most  economically  and  success- 
fully in  similar  cases. 

The  house  is  piped  with  gas,  but  not  wired 
for  electricity  on  account  of  the  expense.    If  the 


ii6  TUBERCULOSIS 

cost  permits,  such  houses  should  be  painted  on 
the  interior,  the  last  coat  being  laid  on  flat;  but 
if  this  is  impossible,  ^Yater  color  can  be  substi- 
tuted. 

Under  favorable  circumstances,  such  a  house 
should  be  built  for  $2,800.  In  smaller  propor- 
tions it  can  be  built  for  $1,650.  What  is  most 
valuable  and  interesting  in  this  individual  work- 
ingman's  house,  which  can  be  constructed  at  so 
low  a  figure,  is  that  there  is  enough  veranda  space 
for  the  majority  of  the  members  of  a  family  to 
sleep  outdoors  if  they  desire  to  do  so.  As  in  the 
open  air  tenement  house,  the  balconies  are  pro- 
vided with  openwork  screens  on  either  side,  these 
being  so  installed  that  they  can  be  folded  back 
during  the  daytime  and  in  fine  weather.  They 
also  serve  to  give  privacy  and  protection  from 
severe  winds. 

The  next  subject  which  we  have  to  consider  is 
the  problem  of  lodging  houses.  Those  who  have 
ever  visited  a  cheap  private  lodging  house  will 
understand  why  I  favor  municipal  lodging  houses, 
which  are  of  necessity  under  better  control.  My 
visits  to  lodging  houses  in  the  various  parts  of 
the  country  have  shown  me  that,  owing  to  the  large 
number  of  individuals  who  usually  occupy  these 
hostelries,  the  ventilation  is  always  insufficient, 
particularly  at    night.     If   there  is  any  class    of 


LODGING  HOUSES  ii; 

buildings  where  our  American  windows  should  be 
replaced  by  the  French  type,  it  is  in  our  private 
and  public  lodging  houses. 

There  is  so  much  tuberculosis  to  be  found  in 
lodging  houses  that  the  transmission  of  the  dis- 
ease from  the  consumptive  lodger  to  the  healthy 
inmate  is  altogether  too  frequent.  In  view  of  the 
fact  that  droplet  infection  is  possible  at  a  shorter 
distance  than  three  feet,  I  consider  any  lodging 
house  law  not  quite  up  to  date  which  does  not 
require  a  passageway  of  at  least  three  feet  be- 
tween the  beds,  and  that  the  beds  should  be  so 
arranged  that  the  air  can  circulate  freely  under 
each  of  them.  At  least  500  cubic  feet  of  air  should 
be  provided  for  each  bed  and  lodger,  and  no  more 
beds  should  be  permitted  than  those  provided  in 
this  way,  unless  unusually  free  and  adequate  means 
of  ventilation  exist  and  are  approved  of  by  the 
local  Board  of  Health. 

The  internal  arrangements  and  sanitation  of 
our  homes  has  as  much  to  do  with  tuberculosis 
as  the  choosing  of  sites  for  future  cities  and  the 
erection  of  buildings,  and  some  of  the  defects 
referred  to  in  the  preceding  paragraph  on  lodg- 
ing houses  are  also  found  in  many  homes  of  rich 
and  poor  alike,  and  even  in  fashionable  hotels. 

We  select  for  our  bedrooms,  as  a  rule,  not  the 
best  but  the  worst  lighted  rooms.    The  majority 


ii8  Tuberculosis 

of  our  city  apartment  and  tenement  houses  are 
built  in  such  a  manner  that  only  the  two  end 
rooms  of  the  flat  receive  direct  air  and  light. 
Thousands  and  thousands  of  persons  in  our 
large  cities  are  thus  compelled  to  spend  their 
nights  in  rooms  where  sunlight  has  never  entered. 
The  strange  custom  of  reserving  the  very  best 
room,  that  is  to  say  the  room  which  might  be  the 
best  lighted  and  best  ventilated,  to  receive  an 
occasional  guest  is  not  confined  to  country  folks 
and  poor  city  apartment  or  tenement  dwellers. 
I  have  seen  this  done  by  well-to-do  people  who 
could  have  done  better  and  should  have  known 
better.  I  recall  one  instance  from  my  own  prac- 
tice where  two  anaemic  children  of  six  and  eight 
years  of  age  were  forced  to  sleep  in  a  dark  bed- 
room and  play  in  the  dark  dining  room  or  ill 
ventilated  kitchen,  while  the  large  front  room,  the 
so-called  parlor,  with  two  large  windows  where  the 
sun  would  stream  in  a  good  part  of  the  day  if 
admitted,  was  locked  all  the  time  except  on  Sun- 
days when  visitors  were  expected.  The  little 
ones  were  not  allowed  to  go  in  there  for  fear 
that  they  might  do  harm  to  the  good  furniture. 
It  was  with  the  greatest  of  difficulty  that  these 
otherwise  good  parents  were  persuaded  to  trans- 
form the  large  parlor  into  a  bedroom  and  playroom 
for  the  children. 


NIGHT  AIR  119 

The  reader  will  recall,  from  what  has  been  said 
before,  that  the  blood  is  one  of  our  most  powerful 
defenses  against  the  invasion  of  bacilli.  In  the 
anaemic  person  the  blood  is  so  impoverished  that 
the  corpuscles  would  no  longer  have  the  power 
to  annihilate  the  germs  of  tuberculosis  if  they 
should  happen  to  enter  the  system. 

Some  people  are  not  only  afraid  of  sunlight  and 
fresh  air  during  the  day,  but  they  are  particularly 
afraid  of  night  air.  The  fear  of  night  air,  this 
nightmare  of  our  ancestors,  has  not  a  little  to  do 
with  the  development  and  propagation  of  indoor 
diseases,  and  particularly  tuberculosis.  In  this 
respect  the  heads  of  institutions  where  there  are 
dormitories  for  the  inmates  are  often  the  greatest 
violators  of  this  first  principle  of  hygiene.  To  have 
two  or  three  and  sometimes  four  children  sleep  in 
one  bed,  whether  in  a  private  home  or  an  institu- 
tion, should  be  considered  absolutely  unhygienic. 
People  should  learn  that  it  is  the  best  economy  in 
the  end  to  use  the  best  lighted  and  best  ventilated 
rooms  for  bedrooms  and  sitting  rooms,  and  when- 
ever it  is  possible  there  should  be  a  single  bed  for 
each  member  of  the  family. 

That  the  method  of  heating  also  has  a  great 
deal  to  do  with  diseases,  particularly  those  of  the 
respiratory  organs,  is  well  known.  From  what 
I  have  learned  by  personal  experience  and  from 


I20  TUBERCULOSIS 

conversations  with  persons  who  are  authorities  on 
the  subject,  it  would  seem  that  the  best  method 
of  heating  buildings  in  general  is  one  that  brings 
warm  fresh  air  into  the  rooms.  The  objection 
to  a  furnace  is  that  it  overheats  a  small  quantity 
of  air  which  it  forces  into  the  rooms  after  it  may 
have  been  burned.  A  better  system,  therefore,  is 
one  of  direct  heating,  whereby  a  large  quantity 
of  moderately  warmed  air  is  brought  into  the 
room  say  over  steam,  or  better  yet,  hot  water  coils. 
A  hot  air  furnace  installation  is  the  cheapest,  and 
is  therefore  the  best  that  can  be  used  for  the  poor. 
Ordinarily,  the  poor  heat  with  stoves  which  com- 
bine the  objectionable  features  of  systems  that 
heat  the  air  contained  in  the  rooms  without  chang- 
ing it,  with  the  objections  to  systems  that  burn 
the  air;  moreover,  presenting  great  danger  of  al- 
lowing gas  to  escape.  Especially  is  carbon  monox- 
ide given  off  through  the  pores  of  the  iron  when 
these  stoves  become  red-hot.  The  usual  systems 
adopted  in  homes  on  account  of  the  balancing  be- 
tween expense,  convenience,  and  hygienic  reasons 
are  steam  heat,  or  better  but  more  expensive,  hot 
water,  with  radiators  placed  directly  in  the  rooms. 
There  are  so  many  cracks  in  tjie  ordinary  house 
that  considerable  ventilation  is  assured.  More- 
over, most  houses  have  fireplaces  which  promote 
some  ventilation  even  if  there  is  no  fire  burning. 


METHOD  OF  HEATING  121 

Many  of  our  American  houses,  however,  are  too 
tightly  built,  are  kept  at  too  high  temperature  and 
the  air  is  not  changed  often  enough.  Besides  all 
this,  the  air  we  breathe  in  many  of  our  overheated 
houses  is  altogether  too  dry  to  be  sanitary.  Ex- 
perience has  proven  that  we  can  be  perfectly  com- 
fortable in  a  temperature  of  65°  F.  and  even  a 
little  lower,  provided  that  the  relative  percentage 
of  moisture  is  60.  If  this  moisture  falls  to  30  or 
20  per  cent,  then  the  dry  throat,  dry  nose,  and  dry 
skin  are  in  evidence.  The  explanation  is  simple. 
The  dry  air  absorbs  the  moisture  from  the  body 
and  causes  discomfort.  The  drying  of  mucous 
membranes  in  this  way  lays  them  open  to  the 
invasion  of  the  organisms  causing  colds,  grippe, 
pneumonia,  and  tuberculosis.  Thus,  the  exces- 
sively dry  atmosphere  of  many  city  and  country 
homes  in  winter  often  gives  rise  to  nasal  catarrh, 
a  condition  which  everybody,  but  especially  those 
suffering  from  pulmonary  diseases  or  prone  to 
them,  should  be  anxious  to  avoid. 

Besides  keeping  the  water  pan  in  the  furnace  con- 
stantly filled,  there  should  be  in  the  sitting  room 
and  sleeping  rooms  some  evaporating  arrange- 
ment, such  as  the  one  known  as  a  humidifier. 
(Fig.  39.)  More  simple  evaporating  devices,  how- 
ever, such  as  a  vessel  filled  with  water  and  a  cloth 
suspended  above  it  touching  the  water  so  as  to 


122 


TUBERCULOSIS 


i  I 


lUMiniFIER'T^ 


(>wi>  i?i=.oisri;i;> 

2\v.\Tl;P  TANKJ 
f    3  SHLlfTS  OF 

OITON  f[-:lt. 


i'lG.  39.     Barnes'  Humidifier. 

produce  capillary  attraction,  will  render  the  at- 
mosphere sufficiently  moist.  To  determine  the 
proper  humidity,  the  direct  reading  hair  hy- 
grometer (Fig.  40)  answers  all  practical  purposes. 
After  vitiated  air,  dust  is  the  next  most  important 
as  a  predisposing  factor  to  tuberculosis.  Even 
the  so-called  sterile  dust  of  the  mineral  or  vegetable 
kind,  if  constantly  inhaled,  will  irritate  and  inflame 
the  respiratory  tract  and  leave  the  mucous  mem- 
brane in  a  condition  for  the  ready  invasion  of  any 
of  the  pathogenic  microorganisms.  It  must  be 
remembered  that  even  in  the  normal  individual 
we  not  infrequently  find  the  pneumonia  producing 
pncumococcus  and  the  Klebs-Leffier  l^acillus  which 
is  the  specific  organism  of  diphtheria.  The  indi- 
vidual a  little  below  par  in  general  health  or  who 


AVOIDANCE  OF  DUST  123 

has  his  upper  respiratory  tract  irritated  by  the 

constant  inhalation  of  dust,  may  thus  fall  a  prey 

to  the  microorganisms  of  pneumonia  or  diphtheria 

of  which  he  was  the  host,  or 

to  the  bacillus  of  tuberculosis 

or    of    grippe    from    external 

sources. 

The  dust  problem  is  so 
great  and  so  important  that 
we  should  give  it  our  special 
attention.  The  amount  of 
dust    that    orie^inates    in    our 

Fig.  40.    Direct  Reading 
houses    from     wear     and     tear.        Hair-hygrometer  to  De- 

etC,    should    be    minimized    by       termine     Humidity    in 
1         .  r-  ,  -I        Rooms. 

havmg  as  tew  carpets  and 
hangings  as  may  be,  and  by  sweeping  and  clean- 
ing in  the  proper  way.  The  following  rules  for 
sweeping  and  dusting  compiled  by  Professor  T. 
Mitchell  Prudden,  a  member  of  our  New  York 
Tuberculosis  Committee,  deserve  the  widest  dis- 
tribution : 

When  you  sweep  a  room  raise  as  little  dust  as  possi- 
ble, because  this  dust  when  breathed  irritates  the  nose 
and  throat,  and  may  set  up  catarrh.  Some  of  the  dust 
breathed  in  dusty  air  reaches  the  lungs,  making  parts 
of  them  black  and  hard  and  useless. 

If  the  dust  in  the  air  you  breathe  contains  germs  of 
consumption  (tubercle  bacilli)  which  have  come  from 


124  TUBERCULOSIS 

consumptives  spitting  on  the  floors,  you  run  the  risk 
of  getting  consumption  yourself.  If  consumptives  use 
proper  spit-cups  and  are  careful  in  coughing  or  sneezing 
to  hold  the  hand  or  handkerchief  over  the  nose  and 
mouth  so  as  not  to  scatter  spittle  about  in  the  air,  the 
risk  of  getting  the  disease  by  living  in  the  same  room  is 
mostly  removed. 

To  prevent  making  a  great  dust  in  sweeping,  use 
moist  sawdust  on  bare  floors.  When  the  room  is  car- 
peted, moisten  a  newspaper  and  tear  it  into  small  scraps 
and  scatter  these  over  the  carpet  when  you  begin  sweep- 
ing. As  you  sweep,  brush  the  papers  along  with  the 
broom  and  they  will  catch  most  of  the  dust  and  hold  it 
fast,  just  as  the  sawdust  docs  on  the  bare  floors.  Do 
not  have  either  the  paper  or  the  sawdust  dripping  wet, 
only  moist. 

There  is  also  an  amount  of  dust,  sometimes 
dangerous,  that  is  carried  in  on  our  shoes  and 
clothing,  especially  on  the  ladies'  long  skirts.  It 
is  to  be  hoped  that  the  requirements  of  health  will 
so  dictate  to  fashion  that  trains  will  never  be  seen 
on  our  streets.  In  the  opposite  event  I  am  willing 
to  be  put  down  as  one  who  favors  the  enactment 
and  enforcement  of  a  law  prohibiting  the  trailing 
of  skirts  in  public  highways. 

When,  on  account  of  the  presence  of  a  tubercu- 
lous invalid  or  susceptible  children  in  the  home, 
one  wishes  to  be  particularly  careful  to  exclude 


AVOIDANCE  OF  DUST  125 

street  dirt,  one  may  have  in  front  of  the  door  lead- 
ing to  his  apartment  an  apparatus  composed  of 
two  blocks  over  which  is  stretched  a  slightly 
moistened  canvas.  After  a  thorough  cleaning  on 
the  mat  or  scraper  outside,  one  passes  his  soles 
over  this  moistened  canvas  for  a  final  cleaning. 
An  ordinary  doormat  may  serve  to  dry  the  moist 
soles.  When,  out  of  consideration  for  the  con- 
sumptive member  of  the  family,  we  wish  to 
diminish  the  dust  which  is  brought  in  on  our  out- 
side garments,  we  should  make  it  a  practice  to 
keep  overcoats  or  dusters  in  a  wardrobe  near  the 
door  and  brush  them  as  well  as  all  other  garments 
in  the  open  air.  It  is  astonishing  how  much  less 
dirt  is  carried  into  the  rooms  if  these  two  simple 
means  are  conscientiously  employed. 

Against  the  dust  which  blows  into  the  rooms 
from  building  material,  we  are  powerless.  Per- 
haps if  Edison's  plan  of  using  reinforced  concrete 
for  the  complete  construction  of  houses  comes  into 
general  use,  we  shall  have  less  dust  to  cope  with. 
This  material  would  seem  to  be  well  adapted  for 
homes  for  the  masses,  as  houses  such  as  the  one 
of  which  the  great  inventor  recently  showed  me 
the  plan,  can  well  be  constructed  for  about  $1,000. 
The  moulds  are  set  up  in  place  and  the  whole 
house  is  made  in  one  piece. 


CHAPTER  VI 

THE     DUTIES     OF     MODERN     MUNICIPAL     HEALTH 

AUTHORITIES 

One  of  the  many  causes  of  impurity  of  the 
atmosphere  in  cities  is  the  imperfect  combustion 
of  fuel.  How  to  do  away  with  the  smoke  nuisance 
is  an  exceedingly  difficult  problem.  In  many  cities 
the  use  of  soft  coal  cannot  be  forbidden  by  law 
because  hard  coal  is  not  available,  or  available 
only  at  a  very  high  price.  It  has  been  demon- 
strated that  with  care  the  skilled  stoker  can  di- 
minish the  amount  of  smoke  produced  even  by 
the  lowest  grade  of  coal.  It  would  thus  seem  that 
in  cities  and  towns  where  hard  coal  can  not  be 
universally  used  on  account  of  its  price,  the  mu- 
nicipality should  offer  gratuitious  instruction  in 
the  proper  methods  of  burning  soft  coal  to  all 
those  handling  furnaces.  Where  this  is  done,  city 
ordinances  should  be  enacted  and  enforced  with 
a  view  to  minimizing  the  smoke  nuisance. 

The  futility  of  merely  placing  an  ordinance  on 

the  law  books  of  a  city  has  been  demonstrated 

by  the  fact  that  Pittsburg,  Cleveland,  Cincinnati, 

126 


PREVENTION  OF  SMOKE  127 

and  Chicago  have  not  been  able  to  make  the 
slightest  headway  against  the  tremendous  pro- 
duction of  smoke.  It  is  only  now  that  Chicago 
is  beginning  to  gain  any  ground,  and  this  is  due 
to  the  fact  that  Mr.  Bird,  the  smoke  inspector, 
has  adopted  entirely  new  tactics.  In  the  first 
place.  Mayor  Busse  has  spent  his  whole  life  in 
the  coal  business  and  knows  more  or  less  about 
smoke  prevention.  He  appointed  Mr.  Bird,  who 
is  a  practical  man,  and  then  arranged  to  give 
him  an  advisory  board  of  three  expert  engineers. 
Among  them  is  Mr.  Bement  who  designed  the 
plant  for  the  Commonwealth  Edison  Company. 
Shortly  after  taking  ofhce,  Mr.  Bird  announced 
that  he  did  not  propose  at  once  to  fine  the  owner 
of  a  building  the  chimney  of  which  was  smoking. 
He  said  that  he  would  go  into  the  fire  room  of  the 
offending  building  and  would  study  conditions. 
He  and  his  advisory  board  would  then  map  out  a 
plan  for  the  prevention  of  smoke,  taking  into 
consideration  the  grade  of  coal  habitually  burned. 
He  would  submit  this  plan  free  of  cost  to  the 
owner  of  the  building  and  would  give  a  reasonable 
length  of  time  for  the  compliance  of  the  owner 
with  these  requirements  of  the  city  department. 
If,  at  the  expiration  of  this  reasonable  time,  the 
■chimney  was  still  smoking  and  no  progress  had 
been  made  toward  the  installation  of  a  new  sys- 


128  TUBERCULOSIS 

tern  which  would  avoid  smoke,  the  law  would  be 
invoked  and  the  maximum  penalty  would  be 
imposed.  I  am  indebted  for  this  information  to 
''A  Practical  Campaign  for  Smoke  Prevention," 
by  George  H.  Gushing,  which  appeared  in  the 
"American  Review  of  Reviews,"  July,  1908. 

From  a  very  interesting  report  on  smoke  in 
relation  to  health,  by  Prof.  A.  Jacobi  of  New 
York,  the  Nestor  of  American  physicians,  who  has 
taken  a  lifelong  interest  in  the  combat  against 
tuberculosis,  we  learn  that  the  latter  disease  and 
also  bronchitis  and  pneumonia  have  decreased 
since  1895  in  London,  Liverpool,  and  Manchester; 
that  is  to  say,  since  the  time  an  active  anti-smoke 
crusade  was  started  in  those  cities.  One  of  the 
most  important  features  of  this  crusade  is  a  law 
limiting  the  time  when  black  smoke  may  be  ex- 
pelled. Thus,  in  London  and  Manchester  no 
factory  chimney  may  expel  black  smoke  for  more 
than  a  minute  every  hour.  In  Professor  Harvey 
Littlejohn's  report  on  causes  and  prevention  of 
smoke  from  manufacturing  chimneys  (city  of 
Sheffield,  1897)  are  enumerated  twenty-two  cities 
which  enforce  a  duration  of  not  more  than  from 
one  to  fifteen  minutes  in  which  black  smoke  may 
be  expelled  each  hour. 

The  official  work  of  the  health  boards  has  been 
aided   by   a   number   of   coal   smoke   abatement 


PREVENTION  OF  SMOKE  129 

societies  in  London  and  elsewhere,  which  employ 
their  own  watchers  and  inspectors  alongside  those 
employed  by  the  government.  It  will  not  be  very 
long  before  manufacturers  and  engineers  will 
cease  to  object  to  the  compulsory  avoidance  of 
smoke  on  account  of  the  acknowledged  economic 
advantage  due  to  a  saving  of  coal. 

That  coal  will  be  replaced  by  gas,  which  burns 
without  smoke,  appears  more  probable  from  year 
to  year.  Even  in  America  where  we  are  some- 
what slow  in  adopting  sanitary  measures,  we  have 
begun  to  replace  coal  by  gas  for  domestic  purposes. 
A  cheap  gas  may  be,  and  has  been  manufactured 
in  South  Staffordshire  and  in  London,  w^hich, 
while  not  fit  for  illumination,  is  perfectly  so  for 
developing  smokeless  heat. 

In  a  presidential  address  before  a  conference 
on  smoke  abatement,  in  1906,  Sir  Oliver  Lodge 
admonished  his  audience  directly  not  to  permit 
the  combustion  of  coal  in  cities,  but  to  insist  on 
the  regular  preparation  of  cheap  gas  instead.  I 
am  afraid  in  America  we  have  been  too  slow  even 
to  utilize  natural  gas  as  we  should  have  done. 

There  is  no  doubt  but  with  a  combined  effort  of 
municipalities,  individual  owners  of  factories  and 
workshops,  and  the  educated  and  willing  citizens, 
much  can  be  done  to  minimize  the  danger  arising 
from    the    incomplete    combustion    of    coal    and 


130  TUBERCULOSIS 

from  the  inhalation  of  organic  and  inorganic 
dust. 

The  smoke  nuisance  in  a  large  city  can  be 
considerably  decreased  by  insisting  that  all  in- 
coming and  outgoing  trains,  from  a  certain  neces- 
sary distance  beyond  the  city  limits,  must  be  drawn 
by  electric  engines  or  by  what  is  called  the  fireless 
locomotive.  This  locomotive,  of  which  the  motive 
power  is  a  steam  tank  filled  at  a  power  station, 
is  suited  for  use  on  railways  where  the  question 
of  fire  protection  is  almost  a  first  consideration, 
as,  for  example,  where  there  are  powder  plants 
or  cotton  mills,  or  on  wharves,  and  other  places 
where  the  presence  of  an  ordinary  type  of  loco- 
motive, or  even  electric  power  would  be  unsafe. 

Some  day  our  federal  government  will  have  to 
step  in  and  help  the  municipal  and  state  govern- 
ments to  solve  this  great  problem.  Our  bureaus 
of  forestry,  geology,  and  commerce  will  have  to 
institute  research  work  in  order  to  minimize  the 
smoke  nuisance,  not  only  on  account  of  the  sani- 
tary conditions  but  for  purely  economic  reasons. 
Millions  and  millions  of  dollars  go  to  waste  by 
inefficient  combustion.  It  is  the  duty  of  the 
government  to  see  that  the  fuel  resources  of  the 
country,  upon  which  the  future  prosperity  of  the 
nation  depends,  are  utilized  to  their  highest  effi- 
ciency. 


GASES  AND  DUST  131 

Besides  the  smoke,  a  modern  city  government 
also  should  strive  to  do  away  with  the  presence  of 
noxious  gases  and  needless  dust.  In  manufactur- 
ing centers  special  ordinances  may  be  necessary 
to  prevent  the  escape  of  poisonous  gases  into  the 
air,  but  in  every  city  we  have  to  cope  with  the 
dust. 

Streets  should  be  sprinkled  regularly  in  dry  and 
warm  weather,  and  while  flushing  them  with  a 
moderate  force  of  water  is  excellent,  too  great  a 
force  wears  pot  holes  in  the  asphalt  paving,  thus 
doing  more  harm  than  good.  A  sprinkling  cart  or 
a  hose  of  small  caliber  should  be  used. 

If  the  street  car  companies  could  be  induced  to 
cooperate  with  the  city  by  sprinkling  their  tracks, 
much  comfort  would  surely  be  assured  to  their 
patrons,  and  some  of  the  dangers  from  dust  re- 
moved. Any  one  who  has  noticed  the  cloud  of 
dust  that  follows  a  swiftly  moving  car  or  the 
amount  that  is  carried  in  by  the  back  draught 
when  the  weather  permits  having  the  rear  doors 
open,  would  appreciate  the  abatement  of  this  un- 
hygienic and  unpleasant  condition. 

As  stated  before,  the  inhalation  of  a  great  deal 
of  dust  has  a  tendency  to  irritate  the  mucous 
membrane  of  the  respiratory  tract,  thus  making 
it  more  vulnerable  to  germs  and  particularly  to 
those  of  tuberculosis. 


132 


TUBERCULOSIS 


Fig.  41.  Knopf's  elevated 
self-cleaning  street  and 
garden  spittoon. 


^' 


Fig.  42.  Knopf -Thiebert 
self-flushing  elevated 
cuspidor  with  cover  for 
railway  stations,  etc. 


The  cleaning  of  streets  should  be  done,  as  far 
as  possible,  during  the  night  and  the  collecting  of 
ashes,  garbage,  etc.,  at  least  in  the  hours  of  the 
forenoon  when  the  traffic  is  at  its  minimum. 
Collecting  ashes  should  be  done  in  such  a  manner 
that  on  windy  days  it  has  no  chance  to  be  blown 
about  during  the  process  of  being  dumped  into 
the  collecting  wagons. 

Public  buildings  which  are  much  frequented 
should  bt  swept  with  moist  sawdust  once  or  twice 


CUSPIDORS  IN  PUBLIC  BUILDINGS        133 

a  day  according  to  the  need.  While  the  tubercu- 
lous sputum  which  has  mingled  with  the  dust  in 
the  street  may  be  considered  less  harmful  because 
it  has  been  exposed  to  light  and  air,  indiscriminate 
expectoration  within  buildings,  halls,  street  cars, 
etc.,  is  absolutely  dangerous;  and  the  enactment 
and  enforcement  of  anti-spitting  ordinances  is  of 
vital  moment,  and  is  one  of  the  most  important 
duties  of  a  municipality.  To  forbid  expectorating 
in  such  and  such  a  place  will  not,  however,  be 
alone  sufficient;  it  is  also  essential  to  provide 
well-kept  cuspidors  in  pubhc  places.  The  ideal 
cuspidor  for  the  purpose  is,  of  course,  the  self- 
flushing  one  with  cover,  having  a  supply  and 
waste  pipe.     (Figs.  41,  42.) 

Every  progressive  municipality  must  be  awake 
to  the  fact  that  to  prevent  tuberculosis,  to  have 
the  consumptive  poor  and  those  of  moderate 
means  cared  for  at  the  right  time,  at  the  right 
place,  and  by  the  right  men,  means  the  sanitary 
and  moral  improvement  of  the  town  or  city,  and 
actual  financial  gain  in  the  end. 

Having  been  associated  for  many  years  with 
the  Health  Department  of  the  City  of  New  York, 
which,  through  its  efficient  work  under  the  leader- 
ship of  Dr.  Hermann  M.  Biggs,  has  accomplished 
so  much  in  the  prevention  of  tuberculosis ;  and  hav- 
ing convinced  myself  of  the  excellent  results  and 


134  TUBERCULOSIS 

collaborated  in  the  work,  I  am  in  a  position  to  speak 
somewhat  in  detail  of  what  the  municipal  health 
authorities  of  the  City  of  New  York  have  been 
and  are  doing,  which  will  serve  as  an  illustration 
of  what  can  and  should  be  done. 

First  of  all,  the  New  York  Health  Department 
keeps  up  a  constant  educational  campaign.  For 
this  purpose  it  issues  a  circular  which  I  reproduce 
here  with  some  slight  modifications  and  additions. 

Consumption  Is  a  Preventable  and  Curable  Disease. 


Information  for  Consumptives  and  Those  Living 

WITH  Them. 


consumption,  also  called  pulmonary  tuberculo- 
sis, IS  chiefly  caused  by  the  filthy  habit  of 

SPITTING. 

Consumption  is  a  disease  of  the  lungs,  which  is  taken 
from  others  and  is  not  simply  caused  by  colds,  although 
a  cold  may  make  it  easier  to  take  the  disease.  It  is 
caused  by  very  minute  germs,  which  usually  enter  the 
body  with  the  air  breathed.  The  matter  which  con- 
sumptives cough  or  spit  up  contains  these  germs  in 
great  numbers — frequently  millions  are  discharged  in  a 
single  day.  This  matter,  spit  upon  the  floor,  wall  or 
elsewhere,  dries  and  is  apt  to  become  powdered  and 
float  in  the  air  as  dust.    Thus  dust  contains  the  germs, 


HEALTH  DEPARTMENT  CIRCULARS       135 

and  thus  they  enter  the  body  with  the  air  breathed. 
Thus  dust  is  especially  likely  to  be  dangerous  within 
doors.  The  breath  of  the  consumptive  does  not  con- 
tain the  germs,  and  will  not  produce  the  disease.  A  well 
person  catches  the  disease  from  a  consumptive  only  by 
in  some  way  taking  in  the  matter  coughed  up  and  spit 
out  by  the  consumptive,  or  coughed  out  with  little  drops 
of  saliva,  even  when  the  patient  does  not  spit. 

Consumption  can  often  be  cured  if  its  nature  be  recog- 
nized early  and  if  proper  means  be  taken  for  its  treat- 
ment.   In  a  majority  of  cases  it  is  not  a  fatal  disease. 

It  is  not  dangerous  to  live  with  a  consumptive  if  the 
matter  coughed  up  by  him  be  promptly  destroyed. 
This  matter  should  not  be  spit  upon  the  floor,  carpet, 
stove,  wall,  or  sidewalk,  but  always,  in  some  sort  of  a  cup 
kept  for  that  purpose.  The  cup  should  contain  w^ater  so 
that  the  matter  will  not  dry,  or  better,  carbolic  acid  in  a 
five  per  cent  watery  solution  (six  teaspoonfuls  in  a  pint 
of  water).  This  solution  kills  the  germs.  The  cup 
should  be  emptied  into  the  water-closet  at  least  twice  a 
day,  and  carefully  washed  with  boiling  water. 

Great  care  should  be  taken  by  consumptives  to  pre- 
vent their  hands,  face,  and  clothing  from  becoming 
soiled  with  the  matter  coughed  up.  Anything  thus 
soiled,  should  be  at  once  washed  with  soap  and  hot 
water.  Men  with  consumption  should  wear  no  beards 
at  all,  or  only  closely  cut  mustaches.  When  consump- 
tives are  away  from  home,  the  matter  coughed  up  should 
be  received  in  a  pocket  flask  made  for  this  purpose.  If 
cloth§  must  be  used^  they  should  be  immediately  burned 


136  TUBERCULOSIS 

on  returning  home.  If  handkerchiefs  be  used  (worthless 
cloths,  which  can  be  at  once  burned,  are  far  better), 
they  should  be  boiled  at  least  half  an  hour  in  water  by 
themselves  before  being  washed.  When  coughing  or 
sneezing,  small  particles  of  spittle  or  mucus  containing 
germs  are  expelled,  so  that  consumptives  should  always 
hold  a  handkerchief  or  cloth  before  the  mouth  during 
these  acts;  otherwise  the  use  of  cloths  and  handkerchief 
to  receive  the  matter  coughed  up  should  be  avoided  as 
much  as  possible,  because  it  readily  dries  on  these,  and 
becomes  separated  and  scattered  into  the  air.  Hence, 
when  possible,  the  matter  should  be  received  into  cups  or 
flasks.  Paper  cups  are  better  than  ordinary  cups,  as  the 
former  with  their  contents  may  be  burned  after  being 
used.  A  pocket  flask  of  glass,  metal,  or  pasteboard,  is 
also  a  most  convenient  receptacle  to  spit  in  when  away 
from  home.  Cheap  and  convenient  forms  of  flasks, 
cups,  and  purses  may  be  purchased  at  many  drug  stores. 
Patients  too  weak  to  use  a  cup  should  use  moist  rags 
which  should  at  once  be  burned.  If  cloths  are  used 
they  should  not  be  carried  loose  in  the  pocket,  but  in  a 
waterproof  receptacle,  which  should  often  be  boiled. 
A  consumptive  should  never  swallow  his  expectoration. 
A  consumptive  should  always  have  his  own  bed,  and 
if  possible,  his  own  room.  The  room  should  always 
have  an  abundance  of  fresh  air:  the  window  should  be 
ojK-n  day  and  night.  The  patient's  soiled  wash,  clothes 
and  bed  linen,  should  be  handled  as  little  as  possible 
when  dry,  but  should  be  placed  in  water  until  ready  for 
washing. 


HEALTH  DEPARTMENT  CIRCULARS       137 

If  the  matter  coughed  up  be  rendered  harmless,  a 
consumptive  may  frequently  not  only  do  his  usual  work 
without  giving  the  disease  to  others,  but  may  also  thus 
improve  his  own  condition  and  increase  his  chance  of 
getting  well. 

Whenever  a  person  is  thought  to  be  suffering  from 
consumption  the  Department  of  Health  should  be  noti- 
fied. If  the  person  has  no  physician,  a  medical  in- 
spector will  call  and  examine  him  to  see  if  he  has  con- 
sumption, and  then,  if  necessary,  will  give  proper  direc- 
tions as  to  treatment. 

Rooms  which  have  been  occupied  by  consumptives 
should  be  thoroughly  cleaned,  scrubbed,  whitewashed, 
painted,  or  papered  before  they  are  again  occupied. 
Carpets,  rugs,  bedding,  etc.,  from  rooms  which  have 
been  occupied  by  consumptives,  should  be  disinfected. 
Such  articles,  if  the  Department  of  Health  be  notified, 
will  be  sent  for,  disinfected  and  returned  to  the  owner 
free  of  charge,  or  if  he  so  desire,  they  will  be  de- 
stroyed. 

When  consumptives  move  they  should  notify  the  De- 
partment of  Health. 

Consumptives  are  warned  against  the  many  widely 
advertised  cures,  specifics,  and  special  methods  of  treat- 
ment of  consumption.  No  cure  can  be  expected  except 
through  the  regularly  accepted  treatment,  which  de- 
pends upon  pure  air,  an  outdoor  life,  nourishing  food, 
and  continuous  medical  supervision. 

Consumptives  unable  to  pay  a  private  physician  will 
receive  treatment  (including  medicines)  free  of  charge 


138  TUBERCULOSIS 

at  the  three  special  tuberculosis  dispensaries  of  the 
Health  Department  (Manhattan,  Fifty-fifth  Street  and 
Sixth  Ave.;  Brooklyn,  361  Jay  Street;  Bronx,  Third 
Ave.  and  St.  Paul's  Place).  To  these  dispensaries 
tuberculosis  cases  may  also  be  referred  by  physicians, 
charitable  organizations,  and  others. 

In  deserving  cases,  milk  and  eggs  will  be  supplied. 
Pocket  sputum  cups  can  also  be  obtained  there,  and  re- 
quests may  be  left  for  nurses  to  visit  patients  at  their 
homes. 

Persons  desiring  additional  information  or  assistance 
should  apply  to  the  Department  of  Health,  Sixth  Avenue 
and  Fifty-fifth  Street,  New  York,  the  Association  for 
Improving  the  Condition  of  the  Poor,  105  East  Twenty- 
second  Street,  or  the  Charity  Organization  Society, 
No.  105  East  Twenty-second  Street. 

If  the  population  for  which  the  circulars  are 
intended  is  presumably  not  able  to  read  English, 
it  is  advisable  to  follow  the  example  of  the  New 
York  Health  Department  which  has  its  popular 
circulars  translated  into  such  languages  as  Bohe- 
mian, Chinese,  German,  Hebrew,  Hungarian, 
Italian,  Polish,  Ruthenian,  Russian,  etc. 

To  encourage  the  foreign  population  within  the 
borders  of  the  United  States  to  study  the  health 
regulations  in  the  language  of  their  adopted 
country,  the  Health  Department  has  the  circular 
in  English  on  one  §id^  of  the  page  and  in  the  Ian- 


HEALTH  DEPARTMENT  CIRCULARS       139 

guage  of  the  country  whence  the  new  American 
citizen  came  on  the  other. 

Besides  this  the  most  important  educational 
leaflet,  cards,  folders,  etc.,  in  much  more  concise 
language,  are  issued  by  the  department  on  which 
at  the  same  time  is  printed  a  list  of  all  the  tuber- 
culosis dispensaries  of  the  city  and  a  map  showing 
where  they  are  located : 

CONSUMPTION. 


How  TO  Keep  from  Getting  It 
How  TO  Keep  from  Giving  It 
DON'T  SPIT 

DEPARTMENT  OF  HEALTH 
CITY  OF  NEW  YORK, 
Hermann  M.  Biggs,  M.  D., 

General  Medical  Officer. 

Thomas  Darlington,  M.  D., 
Commissioner  of  Health. 

CONSUMPTION 

IS  chiefly  caused  by  the  filthy  habit  of 

SPITTING. 

Take  This  Card  Home 

And  Show  It  to  Your  Family,  Friends,  and  Neighbors. 

Consumption  is  a  disease  of  the  lungs,  which  is  taken 
from  others,  and  is  not  simply  caused  by  colds,  although 
a  cold  may  make  it  easier  to  take  the  disease. 


I40  TUBERCULOSIS 

The  matter  coughed  up  and  sneezed  out  by  consump- 
tives is  full  of  living  germs  or  ''tubercle  bacilli,"  too 
small  to  be  seen.  These  germs  are  the  cause  of  con- 
sumption, and  when  they  are  breathed  into  the  lungs 
they  set  up  the  disease. 

Dox't  Get  Consumption  Yourself. 

Keep  as  well  as  possible,  for  the  healthier  your  body 
the  harder  for  the  germs  of  consumption  to  gain  a  foot- 
hold. Every  person  should  observe  the  following 
rules : 

Don't  live,  study,  or  sleep  in  rooms  where  there  is  no 
fresh  air.  Fresh  air  and  sunlight  kill  the  consumption 
germs  and  those  causing  other  diseases;  therefore  have 
as  much  of  both  in  your  room  as  possible. 

Don't  live  in  dusty  air;  keep  rooms  clean;  get  rid  of 
dust  by  cleaning  with  damp  cloths  and  mops. 

Don't  sweep  with  a  dry  broom. 

Keep  one  window  partly  open  in  your  bedroom  at 
night,  and  air  the  room  two  or  three  times  a  day. 

Don't  eat  with  soiled  hands:  wash  them  first. 

Don't  put  hands  or  pencils  in  the  mouth,  or  any 
candy  or  chewing  gum  other  persons  have  used. 

Don't  keep  soiled  handkerchiefs  in  your  pockets. 

Take  a  warm  bath  at  least  once  a  week. 

Don't  neglect  a  cold  or  a  cough,  but  go  to  a  doctor  or 
dispensary 

On  the  back  of  this  card  a  list  of  dispen- 
saries IS  printed. 


HEALTH  DEPARTMENT  CIRCULARS       141 

HOW   TO    GET   WELL    IF    YOU    HAVE    CONSUMPTION. 

If  you  or  any  one  in  your  family  have  consumption, 
you  must  obey  the  following  rules  if  you  wish  to  get 
well  : 

Don't  waste  your  money  on  patent  medicines  or  ad- 
vertised cures  for  consumption,  but  go  to  a  doctor  or 
dispensary.  If  you  go  in  time,  you  can  be  cured;  if  you 
wait,  it  may  be  too  late. 

Don't  drink  whiskey  or  other  forms  of  liquor. 

Don't  Sleep  in  the  same  bed  with  any  one  else  and, 
if  possible,  not  in  the  same  room. 

Good  food,  fresh  air,  and  rest  are  the  best  cures. 
Keep  out  in  the  fresh  air  and  in  the  sunlight  as  much 
as  possible. 

Keep  your  windows  open  winter  and  summer,  day 
and  night. 

If  properly  wrapped  up  you  will  not  catch  cold. 

Go  to  a  sanatorium  while  you  can  and  before  it  is  too 
late. 

The  careful  and  clean  consumptive  is  not  dangerous 
to  those  with  whom  he  lives  and  works. 

Don't  give  consumption  to  others. 

Many  grown  people  and  children  have  consumption 
without  knowing  it,  and  can  give  it  to  others.  There- 
fore every  person,  even  if  healthy,  should  obsen-e  the 
following   rules: 

Don't  Spit  on  the  sidewalks,  playgrounds,  or  on 
the  floors  or  hallways  of  your  home  or  school.  It 
spreads  disease,  and  is  dangerous,  indecent,  and  un- 
lawful. 


142  TUBERCULOSIS 

When  You  ^Iust  Spit,  spit  in  the  gutters  or  into  a 
spittoon  half  filled  with  water. 

Don't  Cough  or  Sneeze  without  holding  a  hand- 
kerchief or  your  hand  over  your  mouth  or  nose. 

Take  this  Card  Home  and  Show  it  to  Your  Family. 

The  New  York  Health  Department  also  issues 
a  circular  to  physicians.  I  reproduce  here  part  of 
this  circular  with  some  slight  changes  which  seem 
to  me  advisable.  The  circular  in  this  shape  will, 
I  hope,  prove  helpful  in  the  crusade  against  tuber- 
culosis as  far  as  the  profession  is  concerned. 

First:  Incipient  tuberculosis  tends  to  recovery. 

Second:  More  advanced  cases  of  tuberculosis 
may  improve  and  life  be  prolonged  and  made  use- 
ful by  proper  care  and  judicious  and  proper 
treatment. 

Third:  In  all  coughs  which  last  more  than  a 
few  weeks  and  which  are  not  associated  with 
asthma,  emphysema,  or  cardiac  diseases,  tuber- 
culosis is  to  be  suspected  as  a  cause. 

Fourth:  Successful  treatment  and  prophylaxis 
demand  the  earliest  possible  diagnosis. 

Fifth:  The  diagnosis  of  incipient  pulmonary 
tuberculosis  properly  so  called,  is  made  positive 
when  tubercle  bacilli  are  found  in  the  expectora- 
tion. 

Sixth:  Repeated  examinations  of  the  expecto- 
ration  are   frequently   necessary   to   demonstrate 


CIRCULAR  TO  PHYSICIANS  143 

the  presence  of  the  tubercle  bacilH  in  incipient 
cases  of  pulmonary  tuberculosis. 

Seventh:  While  the  presence  of  tubercle  bacilli 
in  the  sputum  will  confirm  a  physical  diagnosis 
of  tuberculosis,  the  absence  of  bacilli  in  the  sputum 
does  not  exclude  tuberculosis. 

Eighth:  In  tuberculosis,  suspected  because  of 
the  result  of  a  physical  examination,  the  physician 
should  not  wait  to  inaugurate  the  preventive  and 
curative  measures  until  the  appearance  of  the 
bacilli  in  the  sputum. 

Ninth:  In  order  that  the  bacteriological  ex- 
aminations of  sputa  may  be  at  the  service  of 
physicians  in  all  cases,  the  Health  Department  is 
prepared  to  make  such  examinations,  if  samples 
of  the  sputa,  freshly  discharged,  are  furnished  in 
clean,  wide-necked,  tightly  stoppered  bottles,  ac- 
companied by  the  name,  age,  sex,  and  address  of 
the  patient,  duration  of  the  disease,  and  the  name 
and  address  of  the  attending  physician. 

Permanent  tuberculosis  exhibitions  composed 
of  charts,  photographs,  maps,  models,  diagrams, 
and  all  sorts  of  paraphernalia  that  have  to  do  with 
the  study,  prevention,  and  treatment  of  tubercu- 
losis, should  be  installed  in  all  large  cities.  Thus, 
for  example,  a  life-size  model  of  a  dark  interior 
bedroom,  dirty  and  crowded  with  furniture;  and 


144 


TUBERCULOSIS 


Fig.  43,  A  section  of  the  International  Tuberculosis  Exhibit  held 
in  New  York,  January,  1909,  at  the  Museum  of  Natural  History, 
showing  exhibits  of  various  states  and  countries. 

adjoining  it  a  similar  room  with  open  windows 
and  clean  cot  spread  with  blankets,  between 
which  have  been  sewed  newspapers  as  a  cheap 
and  at  the  same  time  warm  covering,  representing 
the  change  wrought  by  a  visiting  nurse,  will  be 
the  best  ocular  demonstration  of  how  to  prevent 
and  treat  consumption. 

The  photographs  here  reproduced  (Figs.  43  and 
44)  are  illustrations  of  sections  of  the  Interna- 
tional Tuberculosis- Exhibition  which  was  held 
in  New  York  recently,  and  which  must  be  con- 


146 


TUBERCULOSIS 


Fig.  45.    New  l-orms  of  Sneiier  for  Consumptive  Cases  as  Exhibited 
at  the  DubHn  Tuberculosis  Exhibition. 

sidered  one  of  the  most  successful  ever  held  at 
any  time  or  an}^vhere  in  the  world.  During  its 
six  weeks'  stay  in  New^  York,  the  exhibition  was 
visited  by  nearly  a  million  people,  men,  women, 
and  children,  in  all  stations  of  life  and  from  all 
parts  of  the  city. 

Fig.  45  shows  a  section  of  a  local  tuberculosis 
exhibition  recently  held  at  Dublin,  Ireland. 

As  an  educational  measure,  the  New  York 
Health  Department  imitated  the  open  air  lantern 
exhibit  which  originated  with  Dr.  Oscar  H.  Rogers 
of  Yonkers.  During  the  summer  of  1908  in  twenty- 
five  of  the  small  parks  of  the  city  and  at  five  rec- 
reation piers  on  the  river  front,  there  were  shown, 
before  crowds  varying  in  number  from  several  hun- 
dred to  two  or  three  thousand,  a  set  of  stcrcopticon 
slides  giving  in  short  sentences  easily  understood 


LANTERN  EXHIBITS  147 

advice  in  relation  to  tuberculosis.  Interspersed 
with  these  sentences,  pictures  were  thrown  upon 
the  screen  which  showed  the  ways  in  which  the 
bacilli  causing  tuberculosis  are  transmitted  by 
the  cough  and  expectoration  of  those  who  have  it; 
the  effect  of  the  disease  on  the  lungs;  how  over- 
crowded, dirty,  badly  ventilated  rooms  and  tene- 
ments cause  and  spread  it;  how  these  conditions 
are  being  remedied  by  the  enforcement  of  better 
building  laws;  how  the  Department  of  Health 
renovates  rooms  infected  with  the  germs  of  con- 
sumption by  fumigation  and  the  removal  and 
disinfection  of  bedding  and  furnishings;  how  it 
cares  for  patients  in  the  various  hospitals;  and 
finally,  the  possibility  of  arresting  and  curing 
many  cases  in  country  sanatoria. 

Instead  of  giving  a  list  of  the  very  numerous 
slides  which  were  exhibited  in  New  York,  I  will 
give,  as  very  suitable  for  imitation,  a  hst  of  Dr. 
Rogers'  19  views.    They  are  as  follows: 

1.  Plan  of  a  street  in  Yonkers  showing  infected  houses. 

2.  Plan  of  another  street  in  a  different  part  of  the  city. 

3.  A  graphic  illustration  of  the  mortality  among  peo- 

ple of   various  nationalities. 

4.  A  graphic  illustration  of  the  mortality  in  various  oc- 

cupations. 

5.  A  photograph  of  tubercle  bacilli. 

6.  Section  of  normal  lung  showing  air-vesicles. 


148  TUBERCULOSIS 

7.  Section  of  diseased  lung  showing  tubercles. 

8.  A  sketch  showing  infection  through  spitting. 

9.  A    sketch    showing    infection    through    cougliing 

(droplet  infection). 

10.  Photograph  of  a  gelatin  plate  infected  by  a  fly 

which  had  just  been  walking  in  tuberculous  spit. 

11.  A  gelatin  plate  infected  by  bacilli  expelled  by  a 

tuberculous  patient  in  the  act  of  coughing. 

12.  Photographs  of  various  spitcups. 

13.  Dark,  close  room  in  a  tenement,  showing  lounge  on 

which  a  consumptive  lay  dying. 

14.  Same  tenement  with  lounge  near  an  open  window 

and  arranged  by  visiting  nurse — an  effective  il- 
lustration of  the  \alue  of  the  visiting  nurse. 

15.  Home  treatment  on  roof  of  tenement  house. 

16.  Window-tent  for  use  in  home  treatment. 

17.  Shack  treatment  as  carried  on  at  Liberty,  N.  Y. 

18.  Shack  treatment  as  carried  on  at  Wards  Island, 

N.  Y. 

19.  Model  of  inexpensive  shack. 

In  the  large  centers  of  population,  in  fact,  per- 
haps in  all  larger  communities  w^here  there  are 
a  considerable  number  of  poor  or  relatively  poor 
people,  the  tuberculosis  dispensary,  or,  at  least,  a 
special  tuberculosis  class  in  an  ordinary  dispen- 
sary, is  one  of  the  most  important  factors  in  the 
crusade  against  tuberculosis. 

Let  me  state  the  object  and  purpose  of  a  tu- 
berculosis clinic  as  it  has  been  set  forth  in  the 


HEALTH  DEPARTMENT  CLINIC  149 

first  report  of  our  Clinic  for  Pulmonary  Diseases 
of  the  Health  Department,  prepared  by  its  di- 
rector, Dr.  John  S.  Billings,  Jr. 

"  It  was  early  recognized  that  the  establishment  of  a 
tuberculosis  clinic  or  dispensary  would  be  of  great  assist- 
ance in  the  attainment  of  the  following  desired  objects: 

"i.  The  Early  Recognition  and  Accurate  Diagnosis 
of  Pulmonary  Tuberculosis. — It  is  now  generally  ad- 
mitted that  tuberculosis  is  frequently  a  curable  disease, 
and  that  incipient  tuberculosis,  under  favorable  condi- 
tions, tends  to  recovery;  but  to  insure  such  recovery  the 
diagnosis  must  be  made  at  the  earliest  possible  moment. 
Not  only  should  careful  physical  examination  be  made, 
together  with  repeated  sputum  examinations  as  re- 
quired in  connection  with  the  clinical  history,  but  in 
addition,  when  necessary,  the  tuberculin  test.  X-ray  ex- 
aminations and  radiography  should  be  employed  to  as- 
sist in  arriving  at  an  early  and  correct  diagnosis. 

"2.  The  Intelligent  Supervision  of  Patients  Under 
Treatment. — This  supervision  should  include  not  only 
hygienic  and  medical  treatment,  but  also  the  furnishing 
of  circulars  in  various  languages,  containing  informa- 
tion as  to  the  nature  of  the  disease,  and  careful  instruc- 
tions as  to  the  precautions  necessary  to  be  taken  to  pre- 
vent the  infection  of  others.  Paper  sputum  cups,  paper 
handkerchiefs,  and  proper  food  (milk  and  eggs)  should 
be  supplied  to  indigent  and  needy  cases. 

''3,  The  Continued  Observation  of  the  Homes  of 
Indigent,  Needy,  and  Ambulant  Cases,  Including  All 


150  TUBERCULOSIS 

Those  Discharged  from  the  PubHc  Institutions  of  the 
Cily. — A  special  staff  of  trained  nurses  should  visit  the 
patients  at  their  homes  to  see  that  the  instructions  given 
arc  obsen-ed,  that  the  sanitary  surroundings  are  satis- 
factor}',  and  to  aft'ord  such  assistance  as  is  required. 
Suitable  cases  should  be  referred  to  the  various  charita- 
ble organizations  for  food,  fuel,  ice,  etc.  Special  atten- 
tion should  be  paid  to  the  children  in  the  families  of 
tuberculous  persons,  and  every  effort  made  to  prevent 
their  infection. 

"4.  The  Removal  of  Cases  Requiring  Such  Care  to 
Hospitals  or  Sanatoria. — These  cases  fall  under  four 
heads:  (a)  Advanced  or  bedridden  consumptives,  with 
profuse  expectoration,  who  will  not  or  can  not  take  the 
necessary  precautions  against  spreading  the  disease,  and 
whose  presence  at  home  is  a  menace  to  others  in  the 
family;  (b)  consumptives  who  are  able  to  get  about,  but 
who  are  unable  to  work  and  are  entirely  dependent  upon 
their  earnings  for  their  hvelihood;  (c)  incipient  cases, 
who  stand  a  good  chance  of  recovery  if  removed  to  sana- 
toria outside  of  the  city;  (d)  consumptives  living  in  lodg- 
ing houses,  and  those  having  no  home. 

"5.  The  Provision  of  a  Municipal  Institution  to 
Which  Cases  of  Tuberculosis  May  Be  Referred. — 
(a)  By  physicians  (indigent  patients,  etc.);  (b)  by  in- 
stitutions (on  the  discharge  of  consumptive  patients 
from  hospitals  or  sanatoria);  (c)  by  the  various  charita- 
ble organizations  throughout  the  city  which  keep  tuber- 
culous cases  under  observation;  (d)  by  other  persons 
doing  individual  charitable  work  who  may  come  in  con- 


HEALTH  DEPARTMENT  CLINIC  151 

tact  with  such  persons,  and  (e)  by  other  city  depart- 
ments. 

"6.  The  Extension  and  Strengthening  of  the  Sanitary 
Control  of  Tuberculosis  Among  the  Poor  by  the  De- 
partment of  Health. 

"7.  The  Care  of  Laryngeal  Cases. — The  involve- 
ment of  the  larynx  is  one  of  the  saddest  complications  of 
pulmonary  tuberculosis,  and  the  pain,  distress,  and  dis- 
comfort of  the  patients  are  great.  While  the  prognosis 
in  these  cases  is  extremely  grave,  yet  under  proper 
treatment  recovery  takes  place  in  some  instances,  and  in 
most  the  distress  of  the  patient  can,  in  some  degree  at 
least,  be  relieved.  Special  attention  should  be  paid  to 
such  cases  in  a  fully  equipped  throat  clinic." 

For  communities  which  have  not  yet  established 
a  tuberculosis  dispensary,  the  following  sugges- 
tions for  building  and  the  description  of  an  ex- 
isting one  may  be  of  value.  The  ideal  dispensary 
should  be  placed  on  elevated  ground,  in  a  locality 
where  there  is  relatively  little  traffic,  yet  easy  of 
access,  and  where  the  air  is  as  pure  as  can  be 
found  within  the  city  limits.  Not  all  these  ideal 
conditions  existed  when,  in  1903,  the  New  York 
Health  Department  decided  to  establish  its  first 
municipal  tuberculosis  dispensary.  For  obvious 
reasons  the  name  "Clinic  for  Communicable  Pul- 
monary Diseases"  was  decided  upon.  The  lot 
being  narrow,  and  between  high  structures,  and 


152  TUBERCULOSIS 

all  the  available  ground  space  being  required, 
windows  could  only  be  had  on  the  ends.  The 
building  was  therefore  limited  in  height  to  one 
story,  with  a  cellar  below,  in  order  that  each 
room  could  be  lighted  by  a  ventilating  skylight. 
(Fig.  46.)  To  ensure  further  ventilation  square 
openings  were  cut  high  up  in  the  walls  of  the  vari- 
ous rooms,  connecting  them  with  each  other  and 
with  the  halls,  and  electric  fans  were  installed 
in  suitable  places.  The  subdivisions  are  as  fol- 
lows: (i)  entry;  (2)  registration  room  in  which  all 
applicants  are  received,  their  history  taken  and 
all  records  filed ;  (3  and  4)  waiting  room  for  male 
and  female  patients,  each  with  its  water-closet; 
(5  and  6)  dressing  rooms  for  physicians  and 
nurses,  each  containing  a  closet  for  clothes,  a  wash- 
stand  and  water-closet;  (7)  throat  clinic,  with 
complete  outfit,  including  compressed  air  spray 
apparatus,  electric  sterilizer  for  instruments,  in- 
strument cabinets,  and  full  stock  of  all  necessary 
instruments  and  apparatus;  (8)  X-ray  room,  the 
equipment  of  which  consists  of  a  twelve-inch  coil 
with  electrolytic  breaks  and  micro-rheostatic  con- 
trol, Crookes  tubes  of  several  patterns  and  sizes, 
fluoroscopes,  tube  stands,  examination  table,  sup- 
ply and  apparatus  cabinet,  etc.  (a  dark  room  for 
the  immediate  development  of  radiographic  plates 
is  located  in  the  basement  of  the  clinic,  beneath 


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154  TUBERCULOSIS 

the  X-ray  room);  (9  and  10,  11  and  12)  male  and 
female  examination  and  patients'  dressing  rooms, 
containing  desks,  stools,  etc.,  also  a  pneumatic  cab- 
inet for  compressed  or  rarified  air  treatment;  and 
(13)  drug  rooms,  containing  in  enameled  metal 
cabinets  a  full  supply  of  all  medicines  furnished 
by  the  drug  laboratory  of  the  Department  of 
Health.  The  floors  are  of  cement  and  all  corners 
and  angles  are  rounded  to  prevent  accumulation 
of  dirt;  all  furniture  is  enameled  metal.  In  the 
basement,  lockers  are  placed  for  physicians'  and 
attendants'  gowns,  individual  stethoscopes,  etc. 
The  supplies  (blanks,  circulars,  cards,  etc.)  of  the 
clinic  are  also  stored  there.  Large  signs  indicat- 
ing that  it  is  prohibited  to  spit  on  the  sidewalk 
are  placed  at  the  entrance  door  of  the  clinic,  and 
the  following  signboard  in  four  languages  greets 
the  patient  on  his  arrival  in  the  waiting  room: 

Do  not  spit  on  the  floor  or  in  anything  but  in  the 
brown  paper  envelope  furnished  for  the  purpose. 

When  you  cough,  hold  a  piece  of  muslin  before  your 
mouth;  use  the  muslin  also  for  wiping  the  mouth  after 
spitting. 

Men  are  forbidden  to  smoke  or  wear  their  hats  while 
in  the  Clinic. 

Because  of  lack  of  room,  we  had  to  content  our- 
sdves  with  one  door.     Whenever  it  is  feasible,  I 


MUNICIPAL  SANATORIA  155 

would  recommend  having  two  doors,  one  for  the 
entrance  and  one  for  the  exit  of  patients. 

To  avoid  multiplication  of  efforts,  that  is  to 
say,  to  prevent  patients  from  applying  to  several 
dispensaries  at  the  same  time  for  medical  advice, 
medicine,  and  food  in  any  city  where  there  are 
two  or  more  of  such  institutions,  there  should  be 
cooperation  between  these  dispensaries.  If  it  is 
possible  to  divide  the  city  into  certain  districts  with 
dispensaries  located  in  each,  the  work  will  be  all 
the  more  easy.  This  is  done  in  New  York.  A 
patient  living  in  Harlem,  even  if  he  applies  to  a 
down-town  dispensary,  will  be  referred  to  the 
up-town  institution  and  vice  versa. 

The  municipality  will  not  be  able  to  do  effect- 
ive work  in  the  prevention  of  tuberculosis  unless 
it  makes  provision  to  examine  all  the  members  of 
a  family  who  live  with  a  consumptive.  This  is 
particularly  important  when  there  are  children 
in  the  family.  Through  this  careful  examination 
of  all  members  of  any  family,  likely  to  be  exposed 
to  contracting  tuberculosis  or  having  already  con- 
tracted it,  the  greatest  amount  of  preventive  treat- 
ment can  be  inaugurated. 

Every  municipality  should  have  sufficient  hos- 
pital and  sanatorium  facilities  to  treat  the  con- 
sumptive poor,  adults  and  children  who  arc  in 
need   of   institutional   treatment.     To   this   end, 


156-  TUBERCULOSIS 

every  large  city  should  have  a  hospital,  located  at 
not  too  great  a  distance  from  the  city,  where  all 
cases  of  tuberculosis  referred  by  private  practi- 
tioners or  dispensary  physicians  could  be  received 
at  once.  There  they  should  remain  for  a  definite 
time,  sufficiently  long  for  the  visiting  or  house 
physicians  to  determine  whether  it  would  be  better 
for  the  patient  to  remain  there,  return  home  to  rel- 
atives and  friends,  or  be  sent  to  a  sanatorium  at 
a  greater  distance  from  the  city  for  the  purpose  of 
completing  the  cure.  From  the  sanatorium  where 
the  patient's  disease  is  cured  or  arrested,  he  should 
not  at  once  be  permitted  to  return  home  to  his 
former  environment  and  occupation  where  or 
wherein  he  contracted  the  disease,  but  he  should 
be  given  an  opportunity  to  make  his  cure  more 
lasting.  To  this  end  municipalities  should  have 
agricultural  and  horticultural  colonies  where  the 
patient  should  gradually  become  accustomed  to 
harder  work  without  the  fear  of  a  relapse. 

Besides  these  three  kinds  of  institutions,  every 
large  city  should  have  a  special  hospital  or  sana- 
torium to  accommodate  the  children  suffering 
with  diseases  of  the  bones  and  glands,  and  those 
suffering  with  pulmonary  diseases.  To  this  in- 
stitution might  v/ell  be  added  a  division  for  the 
care  of  those  children  of  the  consumptive  poor  who, 
if  they  were  to  remain  at  home,  would  be  likely  to 


MUNICIPAL  SANATORIA  157 

contract  the  disease  from  their  parents.  The  lat- 
ter division  might  justly  be  called  "preventorium." 

Whether  or  not  these  three  institutions  for  chil- 
dren can  be  combined  in  one,  with  a  pavilion  for 
each  kind  of  cases,  or  whether  each  institution 
should  be  located  separately,  will  largely  depend 
upon  the  size  of  the  community  and  the  number  of 
tuberculous  children  in  need  of  care.  While  it  is 
now  generally  conceded  that  tuberculosis  of  the 
bones  and  glands  in  children  is  very  successfully 
treated  at  the  seaside  (Fig.  47),  for  the  comfort  of 
the  inland  communities  it  may  be  said  that  sana- 
toria located  in  any  healthy  region  are  just  as  suc- 
cessful in  the  treatment  of  tuberculous  children. 
(Fig.  48.)  Almshouses  and  orphan  asylums,  by 
reason  of  overcrowding  and  the  commingling  of 
the  tuberculous  with  the  non-tuberculous  inmates, 
very  often  become  centers  of  infection.  The  ex- 
amination for  tuberculosis  of  all  inmates  of  such 
institutions  and  their  periodic  reexamination,  the 
isolating  of  the  tuberculous  from  those  not  affected 
and  the  treatment  of  the  former  according  to  the 
best  and  most  approved  methods  in  the  same  in- 
stitution but  in  different  rooms,  when  it  is  not 
possible  in  special  tuberculosis  institutions,  is  a 
duty  that  must  not  be  neglected. 

It  is  most  important  for  every  municipality  to 
remember  that  a  single  anti-tuberculosis  measure, 


is8 


TUBERCULOSIS 


Fig.  47.  A  porch  of  the  Seabreeze  Sanatorium,  for  children  suffering 
with  surgical  tuberculosis,  at  Coney  Island,  N.  Y.  Established  by 
the  Society  for  Improving  the  Condition  of  the  Poor,  now  main- 
tained by  Mr.  John  I).  Rockefeller. 

while  it  may  be  useful  in  one  direction,  will  not  be 
sufficient  to  solve  the  many  phases  of  the  problem 
presented  in  every  large  city.  It  requires  a  chain 
of  institutions;  a  health  department,  to  educate 
the  masses  and  control  all  existing  cases;  dispensa- 
ries, to  furnish  treatment  and  care  to  cases  among 
the  consumptive  poor  which  can  or  need  not  be 
received  in  the  hospitals  and  sanatoria;  reception 
hospitals,  to  serve  as  a  sort  of  clearing  house  for 


MUNICIPAL  SANATORIA 


159 


Fig.  48.  Inland  Sanatorium.  Country  Branch  of  the  X.  Y.  Ortho- 
paedic Dispensary  and  Hospital  at  White  Plains,  New  York.  Acute 
cases  of  joint  tuberculosis  "  doing  cures  "  in  midwinter. 

hospital  and  sanatorium  cases  where  all  bed  cases 
can  be  received;  and  a  sanatorium  or  sanatoria 
at  a  greater  distance  from  the  city,  for  the  earlier 
and  more  curable  cases  of  adults  and  children. 
Besides  this,  there  should  be  a  disinfecting  station 
or  bureau  for  the  purpose  of  rendering  clean 
and  sanitary  the  premises  occupied  by  the  tu- 
berculous and  also  their  bedding  or  personal 
property. 

A  municipality  having  such  a  chain  of  insti- 
tutions and  a  wide-awake  health  department  with 
police  power  as  the  first  link,  will  not  only  master 
and  control  tuberculosis  within  a  comparatively 


i6o  TUBERCULOSIS 

short  time,  but  will  also  in  the  end  be  the  moral 
and  financial  gainer.  The  Riverside  Hospital- 
Sanatorium  having  300  beds  for  indigent  male 
and  female  consumptives,  receives,  besides  the 
few  forced-in  cases,  annually  a  large  number  of 
New  York's  consumptive  poor  in  the  second  and 
third  stages  of  the  disease.  When  they  improve 
sufficiently  they  are  transferred  to  the  Health 
Department's  Country  Sanatorium  at  Otisville, 
N.  Y.  To  this  latter  institution,  with  a  capacity 
of  250,  early  and  seemingly  curable  cases  are 
sent  directly  from  the  various  dispensaries  of  the 
city.  A  goodly  number  return  from  Otisville 
annually  completely  cured  or  with  their  disease 
sufficiently  arrested  so  that  thsy  can  again  resume 
work. 

Thanks  to  its  police  power,  the  New  York 
Health  Department  has  a  right  to  remove  to  its 
Riverside  Sanatorium  on  North  Brother  Island 
any  individual  suffering  from  tuberculosis  who 
constitutes  a  menace  to  his  family  or  friends. 
The  patient  is  retained  at  this  institution  until  he 
is  cured  or  more  sanitary  arrangements  have 
been  made  at  his  home.  These  so-called  forced-in 
cases  very  soon  become  docile  patients  and  learn 
to  appreciate  the  care  bestowed  upon  them.  The 
accompanying  picture  (Fig.  49)  shows  a  group  of 
the  North  Brother  Island  patients  taking  respira- 


HNANCIAL  AND  MORAL  GAIN  i6i 

tory  exercises  under  the  direction  of  the  physicians 
in  charge. 

To  be  convinced  that  from  these  methods  a 
financial  and  moral  gain  accrues  to  the  com- 
munity, one  only  needs  to  remember  that  when  a 
patient  is  taken  hold  of  in  the  early  stage  of  his 
disease  he  has  a  good  chance  to  be  cured  within 
one  year,  at  little  more  than  he  would  cost  the  com- 
munity for  a  year  in  an  almshouse,  a  general  hospi- 
tal, or  at  home  when  he  or  his  family  had  to  be  sup- 
ported. The  only  difference  is  that  he  may  linger 
at  home  or  in  the  almshouse  an  invalid  for  several 
years  and  never  get  well,  and  before  his  demise 
may  have  infected  all  his  children,  his  wife,  and 
other  relatives  and  friends  who  may  have  come  in 
close  contact  with  him.  Let  us  take,  for  example, 
a  community  which  has  10,000  consumptives  ab- 
solutely poor.  They  will  sooner  or  later  have  to 
be  taken  care  of  by  the  municipality  either  in  the 
almshouse,  general  hospital,  or  their  own  homes. 
They  will  cost  at  the  lowest  possible  rate  in  a 
general  hospital  $7,500  a  day,  or  $2,737,500  a 
year.  In  the  almshouse,  where  no  tuberculous 
patients  should  ever  be,  they  will  at  least  cost 
$5,000  per  day,  or  $1,725,000  a  year.  They  are 
apt  to  Hnger  at  least  two  years  deprived- of  their 
earning  capacity  and,  even  if  they  stay  at  home, 
when  the  consumptive   is  the  breadwinner,   the 


FINANCIAL  AND  MORAL  GAIN  163 

expense  of  maintaining  the  family  is  likely  to  be 
even  higher  than  the  maintenance  of  the  individual 
in  hospital  or  almshouse. 

Now,  it  has  been  demonstrated  that  with  ju- 
dicious administration  and  economy  a  consumptive 
can  be  maintained  and  treated  in  a  sanatorium  at 
$1.00  per  day.  His  chances  of  cure  there  are  at 
least  75  per  cent.  Thus,  the  cure  of  7,500  consump- 
tives would  cost  the  city,  even  if  the  cure  should 
take  a  whole  year,  $2,737,500.  Xot  cured,  they 
would  cost  the  city  at  least  twice  the  amount,  that 
is  to  say,  $5,575,000.  The  remaining  2,500  cases 
not  cured,  will  probably  cost  the  city  $912,500  for 
two  years.  Of  the  latter  many  will  return  to  their 
homes,  if  not  cured,  at  least  temporarily  improved, 
educated  in  the  prevention  of  tuberculosis,  general 
hygiene,  and  personal  cleanliness,  and  by  their 
training  will  become  veritable  missionaries  in  the 
crusade  against  tuberculosis.  Thus,  taking  care 
of  10,000  consumptive  poor  at  the  right  time,  at 
the  right  place  and  in  the  right  way :  that  is  to  say, 
in  the  sanatorium,  in  the  early  and  curable  stages 
of  the  disease,  by  the  most  approved  methods  at 
the  hands  of  experienced  phthisiotherapeutists, 
will  cost  a  total  of  $3,650,000.  Xot  curing  the 
7,500  nor  taking  proper  care  of  the  rest,  will  cost 
the  community  $5,575,000.  Thus,  by  directly 
saving  the  lives  of  7,500  people,  the  community 


i64  TUBERCULOSIS 

has  saved  $1,925,000.  The  number  of  other  valu- 
able lives  which  will  have  been  saved  by  the  isola- 
tion of  the  patients  in  the  proper  institutions  can 
hardly  be  calculated  when  we  remember  that  the 
careless  individual  can  expectorate  seven  billion 
bacilli  in  24  hours,  and  that  it  only  requires  the 
inhalation  or  ingestion  of  a  few  bacilli  by  the  pre- 
disposed individual  to  cause  a  typical  pulmonary 
tuberculosis  to  develop  in  a  relatively  short  time, 
making  him  again  a  center  of  infection,  and  so 
ad  infinitum. 

Consumption  is  a  disease  which  usually  attacks 
an  individual  at  a  time  of  life  when  he  is  most 
useful  and  most  productive,  and  the  economic 
loss  to  the  community  is  naturally  correspondingly 
great  when  it  fails  to  do  its  duty  towards  its  con- 
sumptive poor. 

The  municipality  which  is  in  earnest  to  wipe 
out  tuberculosis  from  its  midst  must  also  make 
provisions  which  tend  to  improve  the  general 
health  of  its  inhabitants,  especially  that  of  its 
children.  There  should  be  plenty  of  parks  and 
playgrounds,  public  baths,  swimming  pools,  and 
gymnasiums.  In  regard  to  the  need  of  play- 
grounds in  cities,  in  the  interest  of  the  health  and 
morals  of  our  children,  the  accompanying  picture, 
''Boys  without  a  playground,"  (Fig.  50)  will 
speak  for  itself.     Parks  are  the  lungs  of  a  city. 


MUNICIPAL  PARKS,  ETC. 


165 


Fig.  50.     Boys  Without  a  Playground, 


The  larger  and  more  numerous  they  are,  the  purer 
will  be  the  air  which  the  inhabitants  will  breathe. 
Playgrounds,  swimming  pools,  and  gymnasiums 
tend  to  make  the  young  more  resistant  to  disease, 
and  particularly  to  tuberculosis. 

A  city  government,  of  course,  always  has  its 
courthouse  and  the  offices  of  its  various  admin- 
istrations. These  offices  should  be  models  of 
ventilation,  proper  heating,  and  lighting.  Anti- 
spitting  ordinances  should  be  enforced  in  munici- 
pal buildings  more  strictly  than  anywhere  else. 
Every  officer  and  employee  of  the  city  government 
whose  duties  are  within  doors  where,  if  tuber- 


i66  TUBERCULOSIS 

culous,  he  might  infect  some  one  else,  should  be 
excluded  from  office  duty  or  indoor  occupation. 
All  city  officials  should  be  examined  for  tuber- 
culosis on  entering  the  employ  of  the  government 
and  should  be  reexamined  for  tuberculosis  at  least 
once  a  year.  The  civil  service  examination  of  all 
city  employees  should  include  questions  on  the 
simple  principles  of  hygiene  and  the  prevention 
of  tuberculosis,  and  a  candidate  not  able  to  an- 
swer the  questions  satisfactorily  should  be  refused 
employment  until  he  has  mastered  these  subjects. 
If  a  municipality  wishes  to  combat  all  possible 
sources  of  tuberculosis,  it  must',  of  course,  see 
that  the  inhabitants  are  provided  with  pure  milk, 
free  from  tuberculous  and  other  germs.  The  surest 
way  of  having  pure  milk  is  to  watch  over  its 
source,  its  transportation,  its  preservation,  and 
its  methods  of  delivery.  Farms  and  dairies  should 
be  inspected,  and  cows  found  tuberculous  on 
physical  examination  or  by  tuberculin  test  should 
be  purchased  by  the  state  or  municipality  and 
disposed  of  by  them.  An  efficient  health  depart- 
ment will  have  visiting  milk  inspectors  who  will 
also  see  that  cows  and  stables  are  kept  clean  and 
that  wholesale  and  retail  milk  dealers  handle  the 
milk  in  such  a  way  that  infection  is  made  virtually 
impossible.  It  has  been  shown  by  the  health  de- 
partments of  a  number  of  American  cities,  such 


MUNICIPAL  PARKS,  ETC.  167 

as  New  York,  Chicago,  Rochester,  and  others, 
that  a  great  deal  can  be  done  in  this  direction  and 
that  a  city  can  be  supplied  with  good,  pure  milk. 
In  the  opinion  of  such  authorities  as  Health  Com- 
missioner Darlington  of  New  York,  Health  Com- 
missioner Evans  of  Chicago,  and  Health  Officer 
Goler  of  Rochester,  the  methods  of  supervision 
of  the  milk  supply  such  as  are  in  vogue  in  their 
cities  are  superior  to  sterilization.  According  to 
the  Year  Book  of  the  U.  S.  Department  of  Agri- 
culture, it  was  demonstrated  at  the  competitive 
exhibit  of  milk  and  cream  at  the  National  Dairy 
Show  in  Chicago  in  February,  1906,  which  was 
in  charge  of  the  Dairy  Division,  that  milk  and 
cream  produced  under  sanitary  conditions  could 
be  shipped  long  distances  and  kept  sweet  for  sev- 
eral weeks,  without  any  other  means  of  preserva- 
tion than  cleanliness  and  low  temperature. 

In  Chapter  II  we  emphasized  the  fact  that 
pasteurized  milk  is  inferior  in  digestive  and  nutri- 
tive qualities  to  raw,  fresh,  pure  milk.  One  of 
the  chief  objections  to  general  and  commercial 
pasteurization,  as  has  been  stated  by  Dr.  M.  J. 
Rosenau,  Director  of  the  Hygienic  Laboratory 
of  the  United  States  Public  Health  and  ]\Iarine 
Hospital  Service,  is  that  such  a  practice  might 
promote  carelessness  and  discourage  the  efforts 
to  produce  clean  milk.    It  is  believed  that  the  gen- 


i68  TUBERCULOSIS 

eral  adoption  of  pasteurization  would  set  back 
improvements  at  the  source  of  supply,  and  en- 
courage dirty  habits.  It  would  cause  the  farmers 
and  those  w^ho  handle  milk  to  believe  that  it  is 
unnecessary  to  be  quite  so  particular,  as  the  dirt 
that  got  into  the  milk  would  be  cooked  and  made 
harmless.  It  would  be  well  if  every  community 
could  have  a  committee  to  teach  mothers  the  im- 
portance of  nursing  their  babies  and,  in  the  event 
of  their  being  unable  to  do  so,  to  teach  them  how 
to  modify  and  prepare  cows'  milk  at  home. 

All  slaughter  houses  should  be  inspected  to 
prevent  the  sale  of  tuberculous  or  otherwise  in- 
fected meat. 

A  very  important  duty  of  every  health  depart- 
ment, be  it  of  a  city,  town,  or  village,  should  be  the 
sanitary  supervision  of  places  of  amusement,  of 
popular,  and  even  of  religious  instruction.  A 
theater,  a  music  hall,  a  dance  hall,  a  lecture 
room,  or  a  church  has  no  right  to  exist  if  its  bad 
ventilation,  bad  or  dangerous  lighting  arrange- 
ments, or  lack  of  j)rovision  against  fire  make  it  a 
menace  to  the  health  and  life  of  the  audience, 
performers,  or  speakers.  I  am  convinced  that  a 
thorough  airing  after  each  performance  and  a 
thorough  cleaning  by  the  pneumatic  process  of 
floor  and  furniture  of  every  theater,  church,  or 
assembly   hall,   would   remove   many  sources   of 


TUBERCULOUS  EMPLOYEES  169 

direct  and  indirect  infection,  not  only  from  tuber- 
culosis but  from  other  communicable  or  con- 
tagious diseases  of  the  respiratory  organs. 

There  are  in  every  community  a  number  of 
tuberculous  individuals  employed  in  occupations 
which  are  not  suitable  for  them,  and  where  their 
presence  is  in  some  degree  dangerous  to  the  com- 
munity at  large.  I  refer  to  bakers  and  confec- 
tioners, milk,  fruit  and  vegetable  dealers,  and 
butchers.  The  community  which  will  insist  that 
any  one  following  these  occupations  must  have  a 
clean  bill  of  health  will  make  another  step  toward 
the  prevention  and  eradication  of  tuberculosis. 

What  has  always  seemed  to  me  rather  unclean 
and  unhygienic  is  the  way  in  which  bread  is  al- 
most universally  handled.  We  have  already  re- 
ferred to  the  possibility  of  infection  from  a  tuber- 
culous baker,  but  the  danger  does  not  end  there. 
The  probability  of  infection  is  still  more  evident 
when  one  considers  through  how  many  hands  the 
bread  passes  before  it  enters  the  mouths  of  the 
consumers,  and  that,  probably,  nobody  ever  thinks 
of  cleaning  bread  before  eating  it.  A  very  recom- 
mendable  practice  is  now  in  vogue  in  some  large 
bakeries  in  connection  with  the  handling  and 
transporting  of  bread.  The  moment  the  bread 
comes  out  of  the  oven,  while  it  is  still  too  hot  to 
be  handled,  it  is  placed,  with  the  aid  of  a  shovel, 


lyo  TUBERCULOSIS 

upon  a  piece  of  wrapping  paper  large  enough  to 
envelop  the  whole  loaf.  By  twisting  the  two  ends 
of  the  wrapper  the  bread  is  completely  enclosed. 

There  are  also  other  sources  of  possible  in- 
fection which  could  be  prevented  by  care  and 
municipal  supervision.  Thus,  for  example,  it 
should  be  against  the  law  to  expose  candy  for 
sale  uncovered.  This  law  should  not  only  be 
applied  to  the  small  candy  dealer  or  peddler,  but 
also  to  the  fashionable  confectionery  stores  or 
department  stores.  The  dust  floating  in  the  air 
of  a  store,  whether  large  or  small,  is  apt  to  be 
infectious  and  should  not  constitute  a  part  of  our 
food. 


CHAPTER  VII 

THE    DUTIES    OF    FEDERAL    AND    STATE    AUTHORI- 
TIES   IN    THE    COMBAT    OF    TUBERCULOSIS 

City,  state,  and  federal  governments  must  work 
hand  in  hand  if  tuberculosis  as  a  disease  of  the 
masses  is  effectually  to  be  combated.  What  has 
been  said  of  the  establishment  of  institutions  for 
the  tuberculous  may  devolve  upon  the  legislators 
of  the  state.  Thus,  it  may  often  be  of  mutual 
advantage  to  have  a  state  institution  to  which  all 
the  cities  and  counties  of  a  state  can  send  their 
incipient  tuberculous  cases.  Such  an  institution, 
most  properly  called  a  sanatorium  (from  the  Latin 
word  sanare,  to  heal),  is  usually  situated  so  that 
it  can  be  easily  reached  from  the  greater  centers 
of  population.  While  high  altitude  and  climatic 
advantages  naturally  favor  the  cure  of  tubercu- 
losis, these  factors  are  by  no  means  indispensable. 

In  the  maxims  on  climatology  we  stated  that 
since  the  majority  of  the  tuberculous  poor  are 
from  the  laboring  classes,  they  should,  as  far  as 
possible,  be  treated  in  the  same,  or  nearly  the 
same  climate  where  they  will  have  to  live  and 

171 


172  TUBERCULOSIS 

labor  after  their  restoration  to  health.  While  the 
cure  in  such  a  home  climate  is  apt  to  take  a  little 
longer  than  in  regions  renowned  for  their  par- 
ticularly congenial  climate,  the  patient's  chances 
for  remaining  cured  are  greater.  This  is  cer- 
tainly the  experience  of  the  majority  of  phthisio- 
therapeutists. 

The  sanatorium  which  is  to  do  the  greatest 
amount  of  good  to  the  largest  number  of  people 
should  not  be  more  distant  from  the  center  of 
population  than  three  to  five  hours  by  rail. 
It  should  be  in  a  region  known  for  the  relative 
purity  of  its  atmosphere  where  there  is  freedom 
from  injurious  gases,  smoke,  and  dust.  If  possi- 
ble, it  should  be  where  the  extremes  of  tempera- 
ture are  not  too  pronounced  and,  if  the  region  is 
a  mountainous  one,  at  an  altitude  of  from  five 
hundred  to  fifteen  hundred  feet.  The  site  should 
be  a  pleasant  one,  with  a  southern  exposure,  and 
protected  from  cold  winds  by  higher  mountains 
and  woodlands  (pine-woods  should  be  given  the 
preference).  The  ground,  of  course,  should  be 
dry  and  porous. 

As  will  have  been  seen  from  our  maxims  on 
climatology  just  referred  to,  it  is  not  absolutely 
necessary  to  fulfill  all  these  conditions.  What 
is  essential  is  the  careful  outdoor  life,  the  judicious 
use  of  cold  water,  plenty  of  good,  plain,  and  nu- 


STATE  SANATORIA  173 

tritious  food,  and  constant  niedical  supervision. 
If  the  choice  had  to  be  made  between  sending 
a  patient  to  what  is  usually  considered  an  ideal 
or  specific  climate,  where  he  would  not  have  any 
guidance  or  supervision  but  would  do  as  he  hap- 
pened to  please,  or  keeping  him  at  home  in  a  fairly 
pure  atmosphere  and  applying  the  hygienic  and 
dietetic  treatment  under  constant  medical  super- 
vision, I  should  choose  the  latter  method  of  treat- 
ment and  think  the  patient  had  a  far  better  chance 
of  recovery. 

After  a  state  legislature  has  provided  a  san- 
atorium for  its  consumptive  poor  and  those  of 
moderate  means,  it  becomes  its  duty  also  to  see 
that  pauperization  is  avoided.  All  persons  seek- 
ing admission  to  a  state  sanatorium  should  be  vis- 
ited by  local  agents  who  should  determine  whether 
the  patient  is  able  to  pay  all  or  only  a  part  of 
his  expenses  during  his  stay  at  the  sanatorium. 
The  first  state  sanatorium  v^as  established  in  the 
United  States  by  the  commonwealth  of  INIassachu- 
setts  in  1895,  and  opened  to  patients  in  October, 
1898.  (Fig.  51.)  It  is  located  near  the  center 
of  the  state,  at  Rutland,  Mass.,  about  fifty  miles 
from  Boston  and  eleven  miles  from  Worcester;  at 
an  elevation  of  1,200  feet.  The  buildings  are  on 
a  southern  slope,  protected  on  the  northwest  by  a 
wooded  hill.    The  pavihons  for  the  patients  are 


STATE  SANATORIA  175 

one  or  two  stories  high,  extending  to  the  south, 
each  terminating  in  a  solarium  and  piazza  (Fig.  52) 
and  all  connected  on  the  north  by  a  covered  corri- 
dor. 

The  primary  object  of  the  institution  is  the 
arrest  of  the  disease,  and  only  such  patients  will 
be  admitted  as  are  deemed  not  too  far  advanced 
for  a  reasonable  hope  of  radical  improvement; 
the  purpose  being  to  give  sanatorium  treatment 
only. 

Residents  of  Massachusetts  only  are  admitted, 
preference  being  given  to  citizens  of  the  United 
States.  Patients  who  do  not  improve  after  a  stay 
in  the  Sanatorium  sufficiently  long  to  test  the  effect 
of  treatment  will  be  advised  not  to  remain,  and 
their  friends  will  be  expected  to  arrange  their 
removal.  In  consideration  of  the  nominal  charge 
made  for  board  and  treatment,  all  patients  who 
are  physically  able  are  expected  to  do  some  work 
daily  under  medical  supervision.  The  institution 
has  a  capacity  for  400  patients  and  the  uniform 
charge  is  $4.00  per  week,  which  covers  less  than 
half  of  the  actual  expense  for  each  patient.  It  is 
difficult  to  estimate  the  great  value  of  such  a 
state  institution  in  the  warfare  ae^ainst  tuberculosis. 
Leaving  aside  the  great  number  of  actual  cures  and 
the  great  educational  influence  such  an  institution 
exerts,  many  patients  returning  improved  to  their 


o 


■"I  ~ 
c 

^  O 

N  3. 


?r 


O 

O 

3 


"I 

n 


STATE  SANATORIA 


177 


former  environments  become  what  might  be  termed 
economic  cures.  In  the  interesting  volume  pre- 
pared by  the  Tuberculosis  Committee  of  the  state 
of  Massachusetts  for  the  International  Tubercu- 
losis Congress  held  at  Washington  last  year,  is 
quoted  a  table  of  comparative  results  expressed  in 
percentage  for  the  first  8  years  of  the  Sanatorium's 
activity.  These  tables  are  most  instructive.  They 
read  as  follows: 


Comparison   of   Percentage    in   the    First,    Second,    Third, 
Fourth,  Fifth,   Sixth,  Seventh,  and  Eighth  Years 


i8g8 

iSgg 

I  goo 

igoi 

igo2 

1903 

igo4 

1905 

to 

to 

to 

to 

to 

to 

to 

to 

iSgg 

I  goo 

igoi 

igo2 

igo3 

1904 

1905 

1906 

Per  cent  of  "arrested"  or  "ap- 

parently cured  "  cases 

34-28— 

42-35 

46.12 

48.31 

48.97 

44.S 

33-7 

39-1 

Per  cent  of  all  classes  of  "im- 

proved" cases 

39-36  — 

44.70 

47.64 

44-51  — 

33-0  — 

47-7 

sS.g 

52.1 

Per    cent   of    "not    improved" 

cases 

26.04 — 

12. gs 

5-74 

6.73- 

7.go  — 

7-4 

7-4 

8.8 

Percentage  of  Incipient  Cases  "Arrested  "  or  "Apparently 

Cured  " 


"Arrested"  or  "apparently  cured" 


iSgS 

to 

iSgg 


64.60 


iSgg 

to 

I  goo 


72. go 


I  goo 

to 

I  go  I 


73.00 


igoi 

to 

igo2 


72.00 


igo2 
to 
igo3 


72.60 


igo3 
to 
1904 


75-8 


igo4 

to 

1905 


64.2 


1905 

to 

igo6 


74-4 


"A  quotation  from  a  study  of  the  subsequent  histories 
of  patients  who  had  left  the  Sanatorium,  taken  from  the 
ninth  annual  report  of  September  30,  1905,  is  also 
added. 


I7S 


TUBERCULOSIS 


''Subsequent  Histories  to  Date  {Oct.  i,  1905)  oj  Former 

Patients  oj  Both  Departments  Treated  in  the  Sa^ia- 

torium  Previous  to  October  i,  1904. 

"The  subsequent  histories  of  former  patients  make 
the  crucial  test  of  any  method  of  treatment,  and  are  of 
vital  importance. 

"For  the  first  time  in  the  history  of  the  Sanatorium, 
tabulations  of  the  results  of  former  treatment  have  been 
made  with  painstaking  care,  and  are  hereby  appended. 
That  they  give  us  convincing  proof  of  the  value  of  the 
work  at  Rutland  during  the  last  six  years  we  think  no 
one  can  deny. 


Total  number  treated 

Able  to  work 

•      1,179 

Not  able  to  work 

34 

No  reply  to  letter 

377 

No  trace 

49 

Dead     . 

.         .         561 

2,200 


Total   number   of    "  arrested "    and 
"apparently  cured" 
Able  to  work 
Not  able  to  work 
No  reply  to  letter 
No  trace 
Dead     .        .        .        , 


2,200 


743 
14 

139 
19 

74^ 


989 


989 


1  Four  have  died  from  causes  other  than  tuberculosis. 


STATE  SANATORIA  179 

"In  reading  these  figures,  it  must  be  remembered, 
moreover,  that  failure  to  receive  repHes  or  inabihty  to 
trace  the  patient  does  not  mean  necessarily  that  the  re- 
sult has  been  unfavorable.  In  many  of  the  earlier  cases 
we  have  failed  to  receive  news  for  months  after  the  first 
inquiries  have  been  made.  Oftentimes,  too,  favorable 
accounts  have  been  received  of  former  patients  through 
others.  It  is  reasonable  to  suppose,  therefore,  that 
many  of  those  from  whom  we  have  not  heard  as  yet  are 
still  alive  and  at  work." 

There  are  now  many  states  which  have  followed 
the  example  of  Massachusetts.  To  statesmen, 
legislators,  and  also  to  private  citizens  a  short  de- 
scription of  the  existing  state  sanatoria,  of  where 
they  are  situated  and  how  they  are  managed,  will 
prove  of  interest ;  and  I  trust  that  to  those  in  whose 
state  there  is  as  yet  no  provision  for  the  tubercu- 
lous, this  splendid  array  of  existing  institutions 
will  be  an  incentive  to  emulation. 

According  to  the  latest  directory  of  our  National 
Association  for  the  Study  and  Prevention  of  Tuber- 
culosis, the  following  states  have  state  sanatoria 
for  consumptives. 

District,  of  Columbia:  "Tuberculosis  Hos- 
pital of  the  District  of  Columbia,"  14th  and  Van- 
ness  Sts.,  N.  W.  (opened  July  i,  1908).  For 
indigent  consumptives  in  all  stages  of  the  disease. 
Capacity  120  beds.    There  are  no  charges, 


i8o  TUBERCULOSIS 

The  grounds  of  the  Sanatorium  comprise  a  plot 
of  30  acres,  overlooking  the  City  of  Washington. 
Two  car  lines  run  within  three  blocks  of  the  insti- 
tution. 

With  the  opening  of  this  hospital,  the  spe- 
cial building  at  the  Washington  Asylum  Hos- 
pital was  closed.  The  new  hospital  is  the  only 
place  in  the  district  for  the  accommodation  of 
consumptive  patients.  Application  should  be 
made  to  the  Board  of  Charities  of  the  District 
of  Columbia. 

Iowa:  ''State  Sanatorium  for  the  Treatment 
of  Tuberculosis"  (opened  February  i,  1908). 
For  the  treatment  of  incipient  cases  or  those  who 
offer  a  fair  chance  of  recovery.  Capacity:  80 
beds.  Rates:  $30  per  month,  for  those  who  are 
able  to  pay;  otherwise  expenses  are  paid  by  the 
state. 

The  Sanatorium  is  located  five  miles  northwest 
of  Iowa  City,  directly  on  the  Cedar  Rapids  and 
Iowa  City  Electric  Interurban  Railway.  The  site, 
which  consists  of  280  acres,  is  of  a  comparatively 
high  altitude,  affording  good  drainage  facilities. 
The  farm  will  be  utilized  for  the  growing  of  vege- 
tables, fruits,  etc. 

The  buildings  consist  of  a  three-story  brick  ad- 
ministration buikling,  two  large  pavilions,  a  power 
house,  and  laundry.     In  the  administrative  build- 


STATE  SANATORIA  i8i 

ing  are  rooms  for  the  superintendent,  the  nurses 
and  other  employees,  as  well  as  offices,  laboratory, 
dining  room,  kitchen,  and  an  amusement  room 
with  open  fireplace.  The  pavilions  consist  of  a 
central  building  with  rooms  for  nurses,  diet  kitchen, 
bath  and  toilet  rooms.  There  are  wings  on  either 
side  containing  ten  rooms  for  two  patients  each, 
and  in  front  is  a  twelve-foot  open  porch.  Accom- 
modations are  thus  afforded  for  eighty,  patients, 
and  the  state  will  doubtless  increase  the  capacity 
as  the  exigencies  require. 

Application  should  be  made  to  the  examining 
physicians  of  the  different  counties,  who  fill  out 
admission  blanks  and  send  them  to  the  superin- 
tendent who,  in  turn,  decides  on  the  suitability  of 
the  applicant. 

Maryland:  "The  Maryland  State  Sanatorium  " 
(opened  in  the  summer  of  1908).  For  all  classes 
of  tuberculosis  which  are  deemed  curable.  White 
persons  only  admitted.  Capacity  is  now  about 
100;  full  scheme  provides  for  250.  Rates:  50 
cents  per  day.  Free  cases  will  be  received  only 
after  approval  of  trustees. 

This  Sanatorium  is  the  outgrowth  of  the  labors 
of  the  Second  Tuberculosis  Commission  of  Mary- 
land, appointed  in  1904.  Up  to  April  i,  1908, 
most  of  the  $100,000  originally  appropriated  had 
been  expended.    The  Legislature  of  1908  appro- 


i82  TUBiERCULOSIS 

priated  $175,000  more  to  complete  the  institution, 
which  will  doubtless  be  one  of  the  finest  state  sana- 
toria in  the  United  States. 

Sabillasville  is  located  in  Frederick  County  in 
the  heart  of  the  Blue  Ridge  iMountains  at  an  eleva- 
tion of  1,500  feet.  The  site  comprises  198  acres. 
The  detached  pavilion  system  of  building  is  being 
employed.  Each  cottage  will  be  sufficiently  far 
removed  from  all  others  to  give  it  plenty  of  air  and 
sunlight.  The  cottages  will  each  accommodate 
sixteen  patients. 

Application  blanks  for  admission  may  be  ob- 
tained from  the  municipal  or  county  health  officer 
in  the  district  in  which  the  applicant  lives,  or  by 
writing  to  any  member  of  the  Board  of  Directors. 
Applicants  must  have  been  residents  of  the  state 
of  Maryland  for  at  least  one  year  preceding  the 
date  of  the  application. 

Michigan:  ''Michigan  State  Sanatorium '^ 
(opened  September  i,  1907).  For  incipient  cases 
only.  Capacity:  38.  Rates:  $1.00  per  day;  $7.00 
per  week.  Those  unable  to  pay  are  cared  for  as 
state  and  county  charges. 

The  Michigan  State  Sanatorium  was  established 
by  a  special  act  of  the  Legislature  in  1905  "for  the 
treatment  of  such  persons  as  shall  be  proven  by 
proper  bacteriologi-clinical  examination  to  be  suf- 
fering from  tuberculosis." 


STATE  SANATORIA  183 

The  Sanatorium  is  situated  two  and  one-half 
miles  southwest  of  the  village  of  Howell,  Living- 
ston County,  at  the  highest  point  of  the  natural 
watershed  of  the  lower  peninsula,  and  is  approxi- 
mately 1,100  feet  above  the  sea-level.  The  prop- 
erty consists  of  270  acres,  192  of  which  was  given  to 
the  state  by  the  citizens  of  Howell,  the  money  being 
raised  by  popular  subscription.  It  is  of  a  rolling, 
sandy  loam,  well  adapted  for  the  growing  of  fruits 
and  vegetables,  and  permits,  from  a  sanitary  point 
of  view,  of  the  best  possible  drainage.  An  ad- 
mirable water-supply  is  secured  from  a  series  of 
natural  springs  on  the  property,  and,  by  pumping 
this  into  an  elevated  reservoir,  ample  pressure  is 
afforded  for  all  practical  purposes  as  well  as  pro- 
tection in  case  of  fire.  A  superior  quality  of  ice  is 
also  secured  from  a  small  lake  at  the  main  entrance 
fed  by  these  same  springs. 

The  Sanatorium  proper  consists  of  an  adminis- 
tration building,  around  which  is  grouped  a  num- 
ber of  shacks.  The  administration  building  con- 
tains the  dining  hall,  offices,  laboratories,  kitchen, 
laundry,  staff  and  help  quarters,  and  two  infirmary 
wings  accommodating  ten  patients  each.  The  in- 
firmary v/ings,  which  are  provided  for  patients 
requiring  special  care  and  nursing,  are  so  con- 
structed as  to  give  perfect  ventilation  and  allow 
each  patient  the  privacy  of  his  own  bedroom  and 


i84  TUBERCULOSIS 

the  opportunity  to  sleep  out  of  doors  on  a  sheltered 
veranda  if  advisable. 

Application  should  be  made  on  printed  blanks 
to  the  superintendent  through  a  regular  examining 
physician. 

Minnesota:  "State  Sanatorium  for  Consump- 
tives" (opened  January  i,  1908).  For  persons  in 
the  early  stages  of  pulmonary  tuberculosis  who 
have  been  residents  of  Minnesota  for  at  least  one 
year.  Capacity:  60.  Rates:  $7.00  per  week.  No 
free  beds,  but  county  and  city  officials  pay  expenses 
of  some  patients. 

This  Sanatorium  is  the  result  of  the  labors  of  a 
commission,  appointed  under  an  act  of  the  Legis- 
lature of  1 90 1,  to  study  the  tuberculosis  question. 
This  same  commission  was  later,  in  1903,  in- 
structed by  the  Legislature  to  erect  a  sanatorium, 
the  state  appropriating  $25,000  for  this  purpose. 

A  location  was  selected  near  Leech  Lake  in  Cass 
County,  740  acres  of  land  were  procured,  and  the 
institutional  buildings  begun.  Two  cottages  and 
one  of  the  wings  of  the  main  building  were  ready 
for  occupancy  on  January  i,  1908.  It  is  near  the 
town  of  Walker,  on  the  Minnesota  and  Interna- 
tional Railway,  200  miles  due  north  of  St.  Paul. 
The  lake,  which  furnishes  an  excellent  water- 
supply,  is  a  quarter  of  a  mile  distant  and  about  200 
feet  below  the  buildings  so  that  the  dampness  from 


STATE  SANATORIA  185 

the  water  will  not  reach  the  patients.  The  sandy 
soil  allows  excellent  drainage.  Railway  facilities 
are  nearby,  the  sanatorium  station  being  on  the 
grounds  one-half  mile  distant  from  the  building. 
There  is  an  admirable  opportunity  for  gardening 
and  grazing,  making  possible  the  production  of 
vegetables,  milk,  and  eggs  for  use  in  the  sanato- 
rium. 

The  buildings  are  planned  especially  for  the 
carrying  out  of  the  open  air  treatment.  The  pres- 
ent main  building  is  but  a  part  of  the  general  plan 
and  has  been  adapted  to  present  needs,  containing 
the  dining  room,  kitchen,  laundry,  apartment  for 
superintendent,  roomis  for  other  employees,  and  a 
ward  each  for  men  and  women  patients,  with 
locker  rooms  and  excellent  bathing  facilities.  The 
piazzas  are  sufficiently  large  for  all  patients  to  sit 
out  at  one  time,  and  are  thoroughly  screened. 
The  two  cottages  are  erected  on  the  plan  of  the 
open  air  ''lean-to,"  used  at  other  sanatoria.  Each 
has  a  central  section,  heated  and  containing  a  sit- 
ting room  and  a  bath  room  well  equipped,  includ- 
ing shower  baths  and  lockers;  and  a  sleeping 
pavilion  extending  out  on  either  side,  open  to  the 
south,  screened  and  provided  with  canvas  cur- 
tains to  be  used  during  inclement  weather.  Pa- 
tients sleeping  in  the  pavilions  are  practically  out 
of  doors. 


i86  TUBERCULOSIS 

Application  should  be  made  to  the  local  medical 
examiners  in  various  parts  of  the  state  or  to  any  of 
the  city  or  county  officials  of  the  poor. 

Missouri:  "^Missouri  State  Sanatorium  for  In- 
cipient Pulmonary  Tuberculosis  "  (opened  August 
1,1907).  For  incipient  cases  only.  Capacity:  50. 
Rates:  $5.00  per  week  for  county  patients;  $50  a 
month  for  private  patients. 

The  IMissouri  State  Sanatorium  for  Incipient 
Pulmonary  Tuberculosis  is  located  in  Mount  Ver- 
non, twelve  miles  from  Aurora  and  sixty  miles 
from  Springfield,  on  a  branch  of  the  Frisco  rail- 
road extending  from  Greenfield  to  Aurora.  The 
Sanatorium  is  situated  on  a  bluff,  with  an  altitude 
of  1,400  feet  above  sea-level. 

The  plans  of  the  architect  call  for  a  group  of 
twelve  or  fifteen  buildings.  There  are  to  be  eight 
villas,  which  will  be  for  the  use  of  patients.  Four 
will  be  for  women  and  four  for  men.  The  villas 
are  one  story  in  height,  so  that  a  thorough  system 
of  ventilation  can  be  installed,  and  so  that  patients 
will  not  need  to  climb  stairs. 

Each  villa  accommodates  twenty-four  patients. 
When  entirely  completed,  the  sanatorium  will 
have  a  capacity  for  200. 

Applications  should  ])e  made  to  the  superin- 
tendent through  the  local  medical  examiners. 

New  Jersey:  ''New  Jersey  Sanatorium  for  Tu- 


STATE  SANATORIA  187 

berculous  Diseases"  (opened  October  25,  1907). 
A  state  sanatorium  for  cases  of  a  curable  nature. 
Capacity:  104.  Rates:  $5.00  per  week.  Patients 
are  admitted  without  charge  whose  inabihty  to  pay 
$5.00  a  week  is  determined  by  a  competent  court. 

The  New  Jersey  State  Sanatorium  for  Tuber- 
culous Diseases  is  located  at  Glen  Gardner,  Hunt- 
erdon County,  on  the  Central  Railroad  of  New 
Jersey,  fifty-two  miles  from  New  York  and  sixteen 
from  Phillipsburg,  about  1,000  feet  above  sea- 
level.  The  site  of  the  Sanatorium  is  on  the  slope 
of  a  mountain  where  the  state  has  acquired  600 
acres.  The  slope  has  been  cut  away  and  leveled 
for  a  considerable  space,  and  here  the  buildings 
are  constructed. 

The  buildings  consist  of  a  service  building, 
administration  building,  and  east  and  west  wards. 
The  service  building  is  84  by  no  feet,  three  stories, 
including  basement,  in  which  is  the  engine  room 
and  electric-light  plant.  Two  boilers  of  125  horse- 
power each,  furnish  steam  to  run  the  dynamos,  and 
the  exhaust  steam  is  utilized  for  heating  the  build- 
ing. 

All  the  buildings  are  built  of  field  stone,  stuccoed 
on  the  outside  and  finished  with  white  plaster  in 
the  interior.  The  floors  are  of  hard  maple  and 
concrete,  and  the  trimmings  are  of  poplar.  Each 
building  has  its  own  heating  apparatus.    Bath  and 


1&& 


TUBERCULOSIS 


\Vinter  View  of  the  New  York  State  Hospital  for  Incipient 
Tuberculosis  at  Ray  Brook,  N.  Y. 

toilet  rooms  are  located  on  each  floor,  with  special 
shower  baths  on  the  second  floor  of  the  ward  build- 
ing. The  buildings  are  so  constructed  that  addi- 
tions may  be  made. 

The  buildings  are  erected  on  the  southern  slope 
of  the  hill  and  are  protected  from  northwesterly 
winds  by  thick  forests  on  the  north  and  west  sides. 
These  forests  in  the  future  will  be  converted  into 
parks  with  shaded  walks  and  drives.  The  grounds 
are  spacious;  tents  and  wooden  shacks  for  sum- 
mer can  be  added  as  they  are  required. 

Application  for  admission  should  be  made  to 
any  one  of  the  local  medical  examiners  who  reside 
in  any  of  the  principal  cities  of  the  state. 

New  York:  ''State  Hospital  for  the  Treat- 
ment of  Incipient  Pulmonary  Tuberculosis,"  Fig. 
53  (opened  July  i,  1904);  situated  at  Ray  Brook, 


STATE  SANATORIA  189 

Essex  County.  Primarily  for  the  poor,  but  pay 
patients  will  be  received  when  there  is  room  for 
them;  one  year's  residence  in  this  state  is  a  re- 
quired condition.  Incipient  cases  only  are  ad- 
mitted.   Capacity:  120. 

By  a  provision  of  its  charter,  the  hospital  is  re- 
quired to  give  preference  to  the  indigent,  admitting 
others  only  when  vacancies  occur.  The  authorities 
by  whom  the  patients  are  sent,  are  required  to  pay 
transportation  to  and  from  the  Hospital  and  $5.00 
per  week  for  maintenance. 

The  State  Hospital  is  located  in  the  Adiron- 
dacks,  four  miles  southeast  of  Saranac  Lake  and 
six  miles  west  of  Lake  Placid.  There  is  an  admin- 
istration building,  with  a  pavilion  on  each  side  con- 
nected with  the  central  building  by  wings  to  be 
used  as  sun  rooms.  The  516  acres  of  land  adjoin 
the  Forest  Preserve.    The  altitude  is  1,625  feet. 

Application  should  be  made  to  the  nearest  public 
authorities  having  charge  of  the  relief  of  the  poor, 
or  to  the  official  medical  examiners,  w^hose  names 
may  be  obtained  from  the  superintendent. 

North  Carolina:  ''The  North  Carolina  State 
Tuberculosis  Sanatorium"  (opened  August,  1908). 
For  incipient  cases  only.  Capacity:  30.  Rates: 
$10.00  per  week,  or  actual  cost  of  maintenance. 

The  site  of  the  new  State  Sanatorium  of  North 
Carohna  comprises  936  acres  of  land,  situated  in  a 


I90  TUBERCULOSIS 

dry,  sandy  country  at  an  elevation  of  650  feet.  The 
Sanatorium  buildings  are  located  on  a  plateau  of 
about  200  acres.  The  site  provides  plenty  of  land 
for  reservation  purposes,  a  good  farm,  an  abund- 
ance of  fuel,  and  water  for  motive  power. 

The  buildings  are  on  the  cottage  plan,  being  18 
by  40  feet  in  dimension,  and  provided  with  piazzas 
14  feet  wide.  The  capacity  of  the  institution  will 
be  enlarged  as  occasion  demands.  It  is  the  inten- 
tion of  the  directors  to  establish  a  camp  about  a 
half  mile  from  the  main  building,  where  patients 
may  be  able  in  part  to  care  for  themselves  at  $7.00 
per  month.  Application  should  be  made  to  the 
superintendent. 

Ohio:  "Ohio  State  Sanatorium"  (opened  Jan- 
uary I,  1909)-  For  incipient  cases  only.  Capacity: 
220.  Rates:  $5.00  per  week.  Ten  per  cent 
of  the  cases  may  be  taken  free  or  at  a  reduced 
rate. 

The  site  of  the  Ohio  State  Sanatorium,  at  Mount 
Vernon,  comprises  335  acres  of  fertile,  porous  soil; 
125  acres  of  woodland.  Two  large  springs,  with  a 
daily  capacity  of  250,000  gallons,  furnish  water 
for  the  Sanatorium.  The  site  is  two  miles  from 
the  city  of  Mount  Vernon,  near  the  center  of  the 
state.  The  capacity  for  100  patients  was  pro- 
vided in  January,  1909.  The  completed  plans 
call  for  more  than  double  this  number  of  beds. 


STATE  SANATORIA  191 

Dr.  CO.  Probst  advocated  paying  $5  a  week  to 
patients  doing  work,  as  an  inducement  to  stay 
and  make  their  cure  more  complete. 

Pennsylvania:  "Pennsylvania  State  South 
Mountain  Sanatorium  "  (opened  in  1908).  For  cit- 
izens of  Pennsylvania  suffering  from  pulmonary 
tuberculosis  and  unable  financially  to  go  to  private 
sanatoria.  Capacity:  350.  There  is  no  charge  ex- 
cept for  laundry,  the  w^ashing  being  for  the  present 
done  at  neighboring  farmhouses.  Patients  are  ex- 
pected to  pay  for  their  own  transportation  and  to 
come  well  supplied  with  clothing.  Shelter  and 
food  are  entirely  free. 

This  Sanatorium  was  made  possible  by  an  ap- 
propriation of  $600,000  by  the  Legislature  of  1907. 
It  includes  and  supersedes  the  small  South  Moun- 
tain Camp  Sanatorium,  formerly  conducted  by  the 
Commissioner  of  Forestry,  and  also  the  private 
Sanatorium  of  the  Doctors  Rothrock.  The  site 
which  includes  about  600  acres  is  in  the  heart  of 
the  Blue  Ridge  Mountains,  on  land  formerly  set 
apart  by  the  Forestry  Commission.  The  grounds 
include  abundant  water-supply  and  facility  for 
water-power,  sewage,  and  drainage. 

As  soon  as  the  money  for  this  institution  was 
made  available,  in  June,  1907,  work  was  at  once 
commenced,  and  by  August  i,  1908,  the  Sana- 
torium had  accommodation  for  350  patients.    The 


192  TUBERCULOSIS 

permanent  unit  of  the  Sanatorium  will  be  a  frame 
cottage  with  the  dimensions  27  by  24  feet,  accom- 
modating two  persons  in  each  of  the  four  equal- 
sized  rooms.  The  cottages  will  be  one  story  high 
with  an  air  space  for  ventilation,  and  will  be  so  ar- 
ranged that  they  can  be  throwm  open  to  the  air, 
but  protected  from  violent  storms  when  necessary. 
The  heating  ^vill  be  by  stoves,  and  the  roofs  built 
of  asbestos  shingles  as  a  safeguard  against  fire. 
The  cottages  will  be  twenty-five  feet  apart  and 
the  streets  will  be  fifty  feet  wide. 

Dining  rooms  will  be  in  common,  one  for  each 
four  hundred  patients.  There  will  be  bath  houses 
provided  w^ith  spray,  douche,  and  shower  baths, 
but  no  bath  tub. 

Dr.  Samuel  G.  Dixon,  State  Commissioner  of 
Health,  says:  ''It  is  anticipated  that  the  South 
IMountain  Sanatorium  will  in  a  few  years  have  a 
capacity  of  three  thousand  patients." 

Application  should  be  made  to  the  County 
Medical  Examiner  in  the  district  where  the  patient 
lives. 

Rhode  Island:  ''Rhode  Island  State  Sanato- 
rium" (Fig.  54),  for  incipient  and  early  cases  of 
tuberculosis.  Capacity:  jio.  Rates:  $5.00  per 
week.  Trustees  may  admit  patients  free  of 
charge. 

The   State   Sanatorium   is   located   at   Wallum 


194  TUBERCULOSIS 

Lake,  650  feet  above  sea  level,  in  the  northwestern 
corner  of  Rhode  Island,  on  the  Providence  to 
Southbridge  branch  of  the  N.  Y.,  N.  H.  &  H. 
R.R. 

The  institution  is  built  on  the  ward  plan  and 
has  a  capacity  of  no  beds.  As  the  Sanatorium  is 
designed  for  the  treatment  of  early  cases,  only 
those  patients  are  admitted  who  present  a  reason- 
able prospect  of  arrest  or  cure,  and  patients  who 
fail  to  improve  after  admission  will  not  be  kept 
indefinitely.  The  charge  is  $5.00  weekly,  payable 
in  advance,  but  the  Board  of  Trustees  has  au- 
thority to  admit  patients  free  of  charge. 

Dr.  H.  L.  Barnes,  who  is  in  charge  of  the  insti- 
tution, remains  in  touch  with  the  physicians  who 
send  patients  there,  not  only  while  they  are  in  the 
institution  but  also  afterwards. 

Wisconsin:  "Wisconsin  State  Tuberculosis 
Sanatorium"  (opened  November  7,  1907).  For 
incipient  and  moderately  advanced  cases  of  tuber- 
culosis. Capacity:  80.  Rates:  $10.00  per  week 
for  those  able  to  pay.  Others  are  admitted  free, 
as  county  charges. 

Wales,  near  which  the  State  Sanatorium  is 
located,  is  on  the  Madison  division  of  the  Chicago 
and  Northwestern  Railroad,  28  miles  west  of  Mil- 
waukee and  54  miles  east  of  Madison. 

The  five  buildings  which  comprise  the  sana- 


STATE  SANATORIA  195 

torium  are  about  two  miles  from  Wales,  at  an  ele- 
vation of  600  feet  above  sea-level.  All  of  the  service 
buildings,  except  the  administration  building,  are 
of  the  "shack"  type  of  construction.  High  moun- 
tains on  every  side  surround  the  Sanatorium  and 
shut  off  the  cold  winds.  When  entirely  completed, 
the  institution  will  cost  $120,000. 

Application  for  admission  must  be  made  by  ex- 
amining physicians  to  the  superintendent.  In  the 
case  of  indigent  patients,  admission  is  by  order  of 
the  county  judge. 

Vermont:  The  State  of  Vermont  has  been  so 
fortunate  as  to  receive  from  Senator  Redfield 
Proctor  as  a  gift,  a  sanatorium  which  has  been 
erected  and  endowed  at  a  cost  of  $200,000.  The 
control  of  the  sanatorium  is  vested  in  a  board  of 
fifteen  trustees,  which  is  a  self-perpetuating  body. 

The  Sanatorium  is  located  near  Pittsford  in  the 
heart  of  the  Green  Mountains,  in  the  western  part 
of  the  state  a  few  miles  north  of  Rutland. 

The  site  consists  of  about  250  acres;  two-thirds 
of  the  tract  is  covered  by  woods  or  growing  trees 
and  affords  a  natural  park  for  summer  camps. 

The  main  building  has  a  frontage  of  over  100 
feet,  the  two  cottages  of  about  80  feet  each;  the 
three  buildings  with  their  connecting  corridors 
make  a  frontage  of  400  feet.  The  buildings  front 
slightly  east  of  direct  south.     They  are  situated 


196  TUBERCULOSIS 

near  the  front  of  a  high  gravelly  plateau.  The 
buildings  are  of  brick  veneer  construction.  The 
interior  finish  is  natural  ash,  with  a  few  rooms  in 
birch.    The  floors  are  of  hard  wood. 

All  patients'  rooms  front  either  direct  south 
or  southwest  or  southeast,  and  each  two  rooms 
have  a  private  outdoor  porch  where  the  patients 
can  sit  out  in  the  daytime  and,  if  desired,  sleep  at 
night.  The  doors  are  so  arranged  that  the  patients' 
beds  can  be  rolled  out  of  the  rooms  on  to  these 
private  porches. 

The  sanatorium  is  intended  for  incipient  and 
moderately  advanced  cases  of  tuberculosis  and  has 
at  present  a  capacity  of  ^2  beds.  The  price  is  $7.00 
per  week.    There  are  no  free  beds. 

Applications  should  be  made  to  the  superin- 
tendent. 

It  is  an  encouraging  sign  that  besides  the  above 
mentioned  states  which  have  already  established 
institutions,  sanatoria  are  at  this  time  either  in  con- 
struction, or  at  least  projected,  in  the  following 
states:  Alabama,  Connecticut,  Indiana,  Kentucky, 
New  Hampshire,  and  West  Virginia.  Equally 
encouraging  is  the  number  of  tuberculosis  dis- 
pensaries established  during  the  last  five  years. 
On  April  i,  1909,  they  numbered  in  the  United 
States  289. 

If   any  community   is   in   earnest    in   its  anti- 


CONSUMPTIVE  CRIMINALS  197 

tuberculosis  work,  it  must  not  limit  its  labors  to 
the  man  and  woman  morally  and  mentally  sound, 
but  must  extend  them  also  to  those  temporarily  or 
seemingly  permanently  unsound  in  mind  and  mor- 
als. I  refer,  of  course,  to  prisoners  and  the  in- 
sane. 

That  consumptive  insane  patients  may  be 
treated  successfully  for  their  tuberculous  lesions, 
and  the  condition  of  their  minds  be  improved  at 
the  same  time,  has  been  demonstrated  during  the 
last  few  years  in  a  large  number  of  American 
insane  asylums.  It  is  a  hopeful  and  encouraging 
sign  that  more  and  more  attention  is  being  paid  to 
this  phase  of  the  tuberculosis  problem,  for  it  can 
not  be  denied  that  in  former  years  many  an  insane 
person  has  contracted  tuberculosis  during  his  stay 
in  the  asylum.  Of  course,  it  must  not  be  forgotten 
that  certain  types  of  insanity  as,  for  example,  the 
hypochondriac  and  others  where  the  physical 
vitahty  in  itself  is  lowered,  strongly  predispose  to 
tuberculosis. 

The  tuberculosis  situation  in  many  of  our  prisons 
and  reformatories  is,  perhaps,  the  most  deplorable 
of  all.  Three  times  as  many  prisoners  die  of  tu- 
berculosis as  free  men.  It  has  been  my  privilege  to 
have  been  commissioned  to  examine  a  number  of 
prisons  and  to  have  appeared  before  associations 
of  prison  physicians  and  general  prison  associa- 


198  TUBERCULOSIS 

tions.  As  a  result  of  all  these  studies  I  plead  to- 
day, as  I  often  have  before,  for  the  examination 
of  every  prisoner  committed  to  a  penal  institution 
at  the  time  of  his  entrance,  and  periodically  after- 
wards; and  I  plead  also  for  the  examination  of 
individuals  in  detention  prisons.  As  far  as  I  could 
learn  from  my  visits  to  detention  prisons  in  many 
states,  prisoners  who  are  simply  held  for  trial  or 
are  waiting  to  be  removed  to  the  penitentiary, 
are  never  examined  by  any  physician  unless  they 
are  quite  ill  and  in  actual  need  of  medical  attend- 
ance, or  obviously  afflicted  with  tuberculosis.  It 
must  be  evident  that  in  this  way  a  latent  tuber- 
culosis has  a  good  chance  to  develop  for,  even 
in  the  better  city  prisons,  the  usual  overcrowding 
will  render  the  atmosphere  vitiated,  particularly 
in  winter.  If  we  add  to  this  the  lack  of  exercise 
and  the  depressing  psychical  influence  of  confine- 
ment, nostalgia,  and  worry,  we  cannot  wonder  that 
prisoners  arriving  at  the  penal  institution  are  often 
found  to  be  tuberculous,  some  even  with  very  ac- 
tive lesions,  while  they  may  have  entered  the  prison 
of  detention  seemingly  in  good  health.  Again, 
some  may  have  been  a  little  below  par,  underfed 
or  weakened  by  exposure,  and  as  a  result  have 
contracted  tuberculosis  from  consumptive  fellow 
prisoners  while  in  jail.  I  say  this  with  no  disre- 
gard for  the  heroic  attempts  of  many  wardens 


CONSUMPTIVE  CRIMINALS  199 

and  physicians  to  render  modern  detention  prisons 
as  sanitary  as  possible. 

In  many  city  prisons  the  accused  sometimes 
await  trial  for  six  months  or  longer.  They  are  not 
occupied  with  anything,  and  are  allowed  to  exer- 
cise in  the  open  air  only  once  a  week  and  for  about 
an  hour  and  a  half.  It  is  well  known  that  many  de- 
tention prisons  are  not  at  all  hygienically  built,  and 
that  there  exist  additional  depressing  factors  in 
many  of  them  well  calculated  to  further  tubercu- 
lous diseases. 

What  can  be  done  to  strike  at  the  root  of  this 
deficiency  in  dealing  with  the  tuberculosis  problem 
in  prisons  ?  A  competent  staff  of  expert  diagnos- 
ticians should  be  attached  to  every  detention  prison 
to  examine  each  prisoner  for  tuberculosis,  syphilis, 
or  other  infectious  diseases.  The  seeming  increase 
of  expense  which  would  arise  from  this,  will 
in  the  end  result  in  a  financial  and  sanitary 
benefit  to  the  community  at  large.  I  can  also 
see  no  reason  why  the  prisoner  who  has  means 
should  not  be  taxed  to  defray  the  expense  for  a 
measure  through  which  he  himself  derives  the 
greatest  benefit.  If  he  is  himself  unknowingly 
afflicted  with  tuberculosis,  the  early  recognition 
may  mean  to  him  the  saving  of  his  life.  If  the 
disease  is  recognized  in  one  of  his  fellow  prisoners, 
he  is  protected  from  contracting  it. 


200  TUBERCULOSIS 

If  prisoners  would  only  have  to  remain  in  de- 
tention prisons  a  short  time,  the  enforced  idle- 
ness with  one  hour  and  a  half  open-air  exercise 
weekly  might  not  be  very  injurious;  but  when 
their  time  of  detention  is  longer  than  three  or 
four  weeks,  a  physical,  mental,  or  moral  deteriora- 
tion is  almost  inevitable.  No  prisoner  should  be 
detained  for  trial  longer  than  four  weeks,  unless 
it  be  in  the  interest  of  justice.  It  is  at  the  very 
beginning  of  incarceration  and  enforced  idleness 
that  these  factors  produce  the  most  depressing 
effects,  and  if  there  is  any  predisposition  to 
tuberculosis,  it  is  sure  to  develop  then.  When- 
ever practicable,  even  detention  prisoners  should 
be  occupied  with  something  useful  and  health- 
sustaining.  By  this  I  do  not  mean  forced  labor. 
Lastly,  there  should  be  some  arrangement  in  the 
detention  prison  to  give  the  prisoner  a  sufficient 
amount  of  exercise  in  the  open  prison  court  to 
assure  his  physical  well-being;  not  weekly,  but 
daily. 

It  would  thus  seem  that  the  first  step  toward 
the  prevention  of  tuberculosis  in  penal  institutions 
should  be  a  most  careful  examination  of  each 
individual,  and  the  weeding  out  and  isolating  of 
all  tuberculous  prisoners  detained  in  jails.  The 
tuberculous  patient  should  remain  isolated  in  the 
detention  prison  as  well  as  in  the  penal  institution, 


CONSUMPTIVE  CRIMINALS  201 

and  he  should  be  given  the  benefit  of  hygienic 
and  dietetic  treatment  from  the  first  moment  he 
becomes  a  ward  of  the  state  or  city. 

When  the  time  for  his  transfer  comes,  the  history 
card  of  his  disease  and  the  recommendation  of 
the  physician  should  be  transmitted  with  the  other 
papers  of  the  prisoner  to  the  penal  institution. 
After  his  arrival  at  the  prison  in  which  he  is  to 
stay  for  some  length  of  time,  the  physician  will  de- 
cide whether  he  is  able  to  work  or  not,  and  what 
kind  of  work  might  be  most  conducive  to  his  re- 
covery. There  is  no  gainsaying  that  the  ideal 
occupation  for  the  tuberculous  prisoner  is  agricul- 
ture or  garden  work. 

I  have  stated  before  that  not  only  should  there 
be  a  careful  examination  of  every  prisoner  for  tu- 
berculosis when  he  enters  the  prison  of  detention 
or  the  penal  institution,  but  his  chest  should  be 
reexamined  periodically  at  least  once  every  three 
months.  With  this  periodical  examination  a  very 
incipient  case,  which  might  have  escaped  detec- 
tion during  the  "entrance"  examination,  is  sure  to 
be  discovered  before  the  disease  has  progressed  to 
any  considerable  extent. 

Expectorating,  except  in  proper  receptacles 
placed  for  that  purpose  in  cells,  workshops, 
chapels,  schools  and  on  the  grounds,  should  be 
punished  by  severe  disciplinary  measures,     That 


202 


TUBERCULOSIS 


there  may  never  be  an  excuse  for  violating  this 
rule,  I  would  go  further.  I  would  not  only  provide 
a  sufficient  number  of  fixed, 
elevated,  suspended  (Fig.  55), 
simple,  or  self-flushing  cuspi- 
dors, such  as  or  similar  to  the 
ones  illustrated  (Figs.  40,  41), 
but  I  would  see  that  each  pris- 
oner has  some  sort  of  pocket 
flask,  or  receptacle  made  of 
metal,  glass,  or  pasteboard. 
(See  Figs.  7,9,  11.) 

A  prison  is,  perhaps,  the  only 
place  in  the  world  where  spit- 
ting regulations  can  be  rigorously 
enforced,  and  it  is  but  fair  that,  if  we  say  to  an  in- 
dividual "don't  spit  here"  and  "don't  spit  there," 
we  should  give  him  a  chance  to  spit  somewhere 
when  he  has  an  excess  of  sahva,  a  cold,  etc.  I  am 
firmly  convinced  that  with  such  a  measure  not 
only  would  tuberculosis  diminish  in  prisons  but 
epidemics  of  pneumonia  or  grippe  would  be  less 
to  be  feared  and  more  easily  controlled.  I  should 
even  like  to  recommend  as  a  regulation  that  every 
prisoner  must  hold  his  hand  before  his  mouth 
when  coughing,  whether  this  coughing  spell  is 
followed  by  expectoration  or  not.  Thus,  tubercu- 
Jous  droplet  infection  will  be  avoided,  and  since 


Fig.  55.  Proedohl's 
Iron  Spittoon  for 
Use  in  Workshops. 


DROPLET  INFECTION  203 

the  coccus  of  pneumonia  is  so  very  prevalent  even 
in  the  mouths  of  healthy  individuals,  this  precau- 
tion may  perhaps  also  tend  to  the  diminution  of 
pneumonia.  As  an  additional  measure  to  prevent 
droplet  infection,  it  might  be  well  never  to  put 
prisoners  too  close  together  at  the  work  tables. 
It  goes  without  saying  that  the  personal  and  bed 
linen  of  the  tuberculous  prisoner,  as  well  as  his 
clothing,  should  be  regularly  subjected  to  disin- 
fection. The  handkerchiefs  of  this  class  of  pris- 
oners should  consist  of  squares  of  cheap  muslin, 
which  should  be  burned  after  use. 

To  judge  from  the  appearance  of  the  various 
kinds  of  blankets,  comforters,  and  quilts  which 
were  lying  on  the  cots  of  the  prisoners'  cells  in 
some  of  the  penitentiaries  I  have  visited,  it  seemed 
to  me  that  these  coverings  might  become  a  means 
of  spreading  infection,  not  only  in  tuberculosis 
but  in  a  good  many  other  communicable  and  con- 
tagious diseases.  The  blanket  and  comforter  are, 
as  a  rule,  the  private  property  of  the  prison  inmate. 
He  brings  these  articles  with  him,  or  they  are 
given  to  him  by  visiting  friends  or  by  fellow 
prisoners  who  have  been  discharged.  In  most 
prisons  these  coverings,  as  well  as  the  clothing 
which  the  prisoner  wears  on  entering  the  penal 
institution,  are  carefully  disinfected.  This  pre- 
caution does  not,  however,  suffice  to  prevent  the 


2o4  TUBERCULOSIS 

bed  covering  from  becoming  thoroughly  infected 
aften^^ards,  particularly  with  the  germs  of  tubercu- 
losis. Pulmonary  tuberculosis  is  so  insidious  in 
the  early  stages  that  the  prisoner  may  have  infected 
his  bed  clothing  long  before  his  disease  has  been 
discovered  by  the  prison  physician,  unless,  of 
course,  frequent  and  thorough  examinations  of 
all  prisoners  are  in  vogue.  To  guard  against  in- 
fection which  may  arise  from  blankets,  comforters, 
etc.,  having  been  soiled  by  infectious  sputum  or 
other  infectious  material,  I  would  suggest  that 
after  thoroughly  disinfecting  these  articles  w^hen 
they  are  brought  to  the  prison,  they  be  incased  in 
a  covering  of  light-colored  washable  material  (not 
necessarily  white),  as  one  uses  a  pillow-case.  By 
basting  the  blanket  in  its  "blanket-case"  it  can  be 
manipulated  with  as  much  ease  as  if  uncovered. 
With  comforters  and  quilts  the  same  method 
should  be  pursued.  There  should  be  two  sets 
of  cases  so  that  the  blankets  need  not  remain  un- 
covered while  one  is  being  washed ;  thus  the  blank- 
ets need  never  come  in  direct  contact  with  the 
prisoner's  body.  I  am  convinced  that  with  such 
a  system  and  with  the  injunction  that  the  washing 
must  be  done  regularly,  one  factor  of  transmitting 
tuberculosis  and  other  infections  from  prisoner 
to  prisoner  will  be  done  away  with. 

Even   the   prisoner  who   is  only  suspected   of 


CONSUMPTIVE  CRIMINALS  205 

having  tuberculosis  should  have  a  separate  cell 
and,  in  any  case,  the  placing  of  two  prisoners  in  one 
cell  should  be  avoided  as  much  as  possible.  The 
bucket  system  for  receiving  the  ejecta  of  prisoners 
during  the  night  and  during  the  day  when  con- 
fined to  their  cells,  is  most  deplorable.  It  is  un- 
sanitary in  general,  and  as  far  as  it  permits  the 
emanation  of  odors  and  gases,  it  is  deleterious 
to  the  health  of  the  inmate.  The  individual  cell 
water-closet,  with  a  perfect  trap  and  cover,  such 
as  is  used  for  example  in  our  New  York  Tombs 
and  other  new  prisons,  is  certainly  to  be  recom- 
mended in  place  of  the  bucket  system. 

The  more  advanced  cases  of  tuberculosis,  par- 
ticularly those  with  constant  fever  and  in  whom 
there  is  disintegration  and  corresponding  abundant 
expectoration  of  bacilli,  should  be  treated  in  special 
wards;  and  in  summer,  perhaps,  in  special  tents 
of  the  prison  hospital. 

In  view  of  the  probable  indifference  to  hygienic 
regulations  of  the  inmates  of  the  hospital,  I  would 
insist,  for  the  purpose  of  preventing  droplet  infec- 
tion, that  all  patients  in  the  more  advanced  stages 
must  wear  a  mouth  mask.  Patients  in  a  number 
of  European  hospitals  for  consumptives  are  told 
to  make  use  of  mouth  masks  in  order  to  protect 
themselves  as  well  as  the  other  patients.  Figure 
56  shows  such  a  device.    It  is  known  as  Professor 


2o6 


TUBERCULOSIS 


Frankcl's  mouth  mask.  I  really  think  it  a  valuable 
means  to  prevent  droplet  infection  which,  with 

the     advanced 

cases     among 

a,  <^g..^y^^^^:B^}::^f^  ^    ^^     consumptives,  is 

quite  a  serious 
factor  in  the 
propagation  of 
the  disease.  By 
impregnating 
the  gauze  which 

Fig.  56.     Frankel's  Mouth  Mask.  j^  j^^j^   j^  pj^^^ 

by  the  metallic  frame  of  the  mask  with  some  me- 
dicinal substance,  the  inhalation  of  which  allays  the 
cough  and  is  soothing  to  the  inflamed  pulmonary 
surface  as,  for  example,  10  or  15  drops  of  a  mixture 
composed  of  equal  parts  of  menthol,  eucalyptus 
oil  or  creosote,  and  spirits  of  chloroform,  the 
prisoner  wearing  the  mouth  mask  is  likely  to  be 
benefited  and  the  protection  of  others  is  assured. 

The  custom  of  whitewashing  a  room  in  which 
ordinary  and  healthy  individuals  stay  but  a  short 
time  might  be  considered  a  hygienic  procedure. 
When,  however,  this  process  has  been  adopted 
for  the  sake  of  doing  away  with  tlie  danger  of 
tuberculosis,  I  doubt  its  efhcacy.  If  a  cell  has 
been  previously  occupied  by  a  tuberculous  pris- 
oner, he  will  surely  have  infected  its  walls;  if  not 


DANGER  FROM  WHITEWASH  207 

directly  by  expectorating  on  them,  he  will  have 
done  so  by  droplet  infection.  Whitewashing  is 
well-nigh  useless  in  such  a  case,  since  dried  white- 
wash is  apt  to  scale  off,  especially  when  there  are 
several  coats,  and  it  will  produce  a  certain  amount 
of  dust  in  a  small  room  like  a  cell.  This  dust  is 
irritating  to  a  sensitive  lung,  and  it  is  not  unlikely 
that  it  may  be  an  aggravating  factor  with  prisoners 
who  enter  the  penal  institution  only  slightly 
tuberculous,  or  predisposed.  The  new  occupant, 
if  at  all  debilitated,  physically  or  mentally  de- 
pressed, is  much  exposed  to  the  contraction  of 
tuberculosis  in  such  an  environment.  The  new 
coat  of  whitewash  is  apt  to  scale  off  with  the  un- 
derlying infected  layer,  and  turning  into  dust 
makes  an  infection  by  inhalation  par  excellence. 

That  tuberculous  germs  may  be  inhaled  from 
infected  walls  has  been  demonstrated  again  and 
again,  not  only  inside  of  prisons,  but  in  the  tene- 
ment houses  of  the  poor  and  even  in  the  apartments 
of  the  rich.  My  friend  Dr.  Ransom  of  the  Danne- 
mora  prison,  with  whom  I  had  many  conversa- 
tions on  the  subject,  expresses  himself  as  follows: 
"Observation  and  experiment  show  that  white- 
wash really  promotes  the  spread  of  tuberculous 
disease.  The  fine  scales  and  floating  particles 
that  emanate  from  the  dried  whitewash,  when 
disturbed,  not  only  irritate  the  bronchial  mucous 


2o8  TUBERCULOSIS 

membranes,  but  they  are  also  carriers  of  infection 
to  the  point  irritated." 

To  remedy  the  danger  arising  from  whitewash- 
ing small  cells,  I  would  suggest  that  the  white- 
wash be  replaced  by  oil  paint  which  can  be  washed 
with  disinfecting  fluids.  The  cells  should,  of 
course,  never  be  smaller  than  five  hundred  to 
six  hundred  cubic  feet,  w^ll  ventilated  and  well 
lighted  by  natural  light  in  daytime,  and  by  elec- 
tric light  at  night  (gas  illumination  absorbing  too 
much  oxygen). 

As  to  the  general  sanitation  of  prisons  as  far 
as  it  is  related  to  tuberculosis,  I  only  wish  to  say 
that  a  prison  with  all  its  annexes  should  be  con- 
structed so  that  there  is  plenty  of  light  and  venti- 
lation, and  on  a  soil  that  is  dry  and  porous. 

To  avoid  acquiring  a  predisposition  or  develop- 
ing an  incipient  case,  I  would  suggest  the  follow- 
ing: All  prisoners  should  be  given  a  chance  to 
exercise  several  times  during  the  day  in  the  open 
air,  even  if  only  for  a  short  time,  and  during  that 
time  they  must  not  only  be  permitted,  but  should 
be  enjoined  to  take  deep  inhalations,  or  better  yet, 
regular  respiratory  exercises.  The  exercise  in  the 
open  air  should,  however,  not  be  limited  to  week- 
days. According  to  the  prison  regulations  now  in 
vogue  in  most  penal  institutions,  prisoners  are 
confined  to  their  cells  not  only  from  the  hour  of 


EXERCISES  FOR  PRISONERS  209 

five  in  the  afternoon  to  six  in  the  morning,  but 
also  during  almost  the  entire  twenty-four  hours  of 
Sundays  and  holidays,  and  when  a  holiday  follows 
a  Sunday,  or  vice  versa,  the  prisoners  are  necessa- 
rily locked  up  in  their  cells  for  two  successive  days. 
That  such  close  long  confinement  in  a  small,  ill- 
ventilated  cell  must  be  harmful  is  self-evident. 

In  well-conducted  prisons  the  inmates  are  re- 
quired to  bathe  regularly,  and  their  skin  is  usually 
in  good  condition.  To  the  prisoner  predisposed 
to  tuberculosis  or  one  whose  case  is  so  incipient 
that  constant  medical  supervision  is  not  neces- 
sary, permission  for  daily  cold  douches  should  be 
given.  To  this  class  of  prisoners,  predisposed  or 
incipient,  it  seems  to  me  also  that  it  would  pay 
the  state  to  give  food  containing  a  little  more  of 
the  nitrogenous  substances  and  the  carbohydrates 
than  the  regular  prison  fare  now  supplies. 

One  predisposing  factor  to  tuberculosis  in 
prisons,  which  seems  to  have  been  overlooked 
in  most  of  the  reports  on  the  subject,  is  over- 
working the  prisoners.  While  it  is  true  that  in 
the  majority  of  prisons  the  hours  of  work  are 
rarely  more  than  those  of  the  average  free  laborers, 
we  must  not  forget  that  the  free  man,  laboring 
eight  or  ten  hours  a  day,  has  a  relatively  better 
quality  of  food,  the  exhilarating  influence  of 
freedom  of  action,  and  naturally  superior  hygiene. 


2IO  TUBERCULOSIS 

I  do  not  wish  to  make  this  statement  in  the  spirit 
of  criticism,  but  simply  to  point  out  the  general 
likelihood  of  a  predisposed  individual  develop- 
ing tuberculosis  more  rapidly  under  conditions  of 
confinement  than  when  in  normal  environments. 

It  is  not  necessary  to  speak  of  any  particular 
prison  here,  but  in  many  of  them  the  workshops  are 
very  badly  ventilated,  overcrowded  with  workers, 
often  overheated,  and  where  there  should  be  dust 
collectors  these  are  wanting.  Tobacco  workers, 
for  example,  are  prone  to  tuberculosis  under  the 
best  conditions.  How  much  more  must  they 
be  in  danger  in  a  prison  workshop  full  of  dust, 
where  there  is  hardly  elbow  room  and  where  the 
air  is  greatly  vitiated !  Since  it  is  a  very  common 
practice  for  cigarmakers  to  paste  the  final  leaf  with 
saliva,  it  must  be  evident  that  no  prisoner,  even 
slightly  afflicted  with  tuberculosis,  should  be  per- 
mitted to  make  cigars,  leaving  aside  the  fact  that 
such  conditions  are  sure  to  aggravate  his  disease. 

I  can  not  leave  the  subject  of  tuberculosis  in 
prisons  without  referring  to  one  phase  of  it  which 
appertains  rather  to  the  welfare  of  the  community 
at  large.  I  refer  to  the  pardoning  of  prisoners  far 
advanced  in  tuberculosis.  Whether  the  practice 
of  restoring  the  pardoned  prisoners  to  their  often 
poor  families  is  always  a  wise  one,  I  venture  to 
question  seriously.    It  is  sad  enough  that  prisoners 


EXERCISES  FOR  PRISONERS 


211 


who  have  contracted  tuberculosis  in  prison,  or 
whose  tuberculosis  has  been  aggravated  through 
prison  life,  should  be  discharged  upon  the  com- 
munity at  the  expiration  of  their  sentence  without 
any  regard  to  where  they  will  go  or  what  they 
will  do.  They  will  invariably  constitute  a  source 
of  infection  unless  they  have  been  prophylactically 
trained  and  are  willing  to  continue  to  be  careful. 
Prisoners  virtually  dying  from  tuberculosis  should 
not  be  pardoned  and  sent  home,  unless  the  au- 
thorities are  sure  that  the  unfortunate  sufferer  will 
be  able  to  find  support  and  not  become  a  source 
of  infection. 

The  treatment  of  advanced  cases  has  already 
been  referred  to,  but  in  this  connection  I  wish  to 
say  a  word  about  the  admirable  w^ork  done  at 
the  Texas  tuberculosis  agricultural  prison  colony, 
known  as  the  Wynne  State  Farm,  under  the  scien- 
tific and  humane  management  of  Dr.  Fowler. 
The  statistics  of  four  years'  working  of  this  farm 
are  as  follows : 


Total  number  discharged 

•       34 

(I                     u 

pardoned 

.       30 

ft            il 

transferred 

.       37 

il             11 

died 

.        .       46 

it               a 

on  hand 

•       33 

Total  number  treated 

.     180 

212  TUBERCULOSIS 

At  the  conclusion  of  Dr.  Fowler's  interesting 
report  he  comments  on  the  statistics  as  follows: 
''I  will  say  that  the  thirty-seven  men  transferred 
are  virtually  cured,  at  least  one-half  of  those 
pardoned  and  discharged  were  in  good  physical 
condition,  and  the  majority  on  hand  are  improv- 
ing. The  labor  of  the  one  hundred  and  eighty 
men  was  practically  of  no  value  anywhere  else  in 
the  prison  as  most  of  them  had  reached  an  ad- 
vanced stage  of  tuberculosis  before  their  recep- 
tion at  the  Wynne  Farm.  The  farm  is  more  than 
self-sustaining,  if  the  expense  of  guarding  the 
prisoners  is  deducted.  The  men  all  occupy  the 
same  building,  as  they  have  to  be  guarded  day 
and  night." 

From  the  report  it  is  evident  that  tuberculosis 
has  been  on  the  decrease  in  that  prison,  and  there 
is  no  doubt  in  my  mind  that  the  tuberculous 
prisoner,  cured  by  a  healthful  and  invigorating 
agricultural  pursuit,  will  be  returned  to  society 
after  the  expiration  of  his  sentence  many  times  a 
better  member  of  it  than  he  was  formerly. 

A  most  important  feature  in  the  prevention  of 
tuberculosis,  or  more  exactly,  in  the  prevention 
of  a  predisposition  to  tuberculosis,  is  the  restric- 
tion of  child  and  woman  labor.  It  is  impossible 
to  resist  the  invasion  of  the  bacilli  when  the  in- 
dividual  is   in   a  state   of  physiological  poverty. 


WOMAN'S  AND  CHILD  LABOR  213 

This  condition  is  sometimes  called  being  "below 
par."  A  woman,  who  in  perfect  health  and  under 
normal  conditions  may  do  her  physical  and  mental 
labors  as  well  as  anybody  else,  should  not,  in  a 
civilized  and  enlightened  country,  be  allowed  to 
work  in  either  factory,  workshop,  sweatshop,  or 
at  home  until  virtually  the  last  day  before  her 
delivery;  nor  should  she  be  allowed  to  resume  her 
labors  until  a  month  or  two  after  confinement. 
That  horrible  condition  known  as  child  labor, 
still  in  existence  in  some  of  our  states,  should  for- 
ever be  done  away  with,  and  laws  should  be 
enacted  and  enforced  that  will  make  it  impossible 
for  a  child  to  be  forced  to  spend  hours  and  hours, 
sometimes  ten,  twelve,  or  fourteen  a  day,  in  a 
factory  or  workshop,  often  under  the  most  un- 
hygienic conditions. 

The  growing  organism  of  a  child  is  in  need  of 
all  the  fresh  air  and  outdoor  exercise  it  can  pos- 
sibly get,  and  to  confine  it  indoors  during  the 
years  of  its  physical  development,  often  in  an 
overheated,  dusty,  and  smoky  atmosphere,  and  to 
overtax  its  muscular  and  nervous  system  by  long 
hours  of  work,  is  the  very  thing  which  causes  the 
physiological  poverty  above  referred  to.  If  a 
child  has  contracted  tuberculosis  during  infancy, 
and  because  of  a  certain  amount  of  outdoor  play 
and  good  care  during  early  childhood  the  tuber- 


214  TUBERCULOSIS 

culosis  has  become  latent,  though  not  entirely 
cured,  it  is  almost  certain  to  develop  and  become 
active  if  he  is  put  to  work  between  the  ages  of  ten 
and  fourteen.  The  child's  body  is  arrested  in  its 
development  and  his  chest  capacity  becomes  much 
below  normal.  Lack  of  sleep  and  recreation  cause 
him  to  become  an  easy  prey  to  the  tubercle  bacilli 
under  these  conditions,  even  if  his  system  has 
not  been  invaded  by  them  in  infancy.  No  child 
between  the  ages  of  eight  and  fourteen  should  be 
allowed  to  do  more  than  his  school  work.  The 
home,  the  school,  and  the  playground  should  be  his 
only  abodes. 

By  reason  of  their  environment,  and  unfortu- 
nately also  often  by  reason  of  example  in  home  or 
workshop,  children  that  are  compelled  to  work 
become  very  readily  addicted  to  the  use  of  alcohol. 
Their  humdrum  existence  often  makes  them  in- 
different to  any  moral  issue;  their  weakened  ner- 
vous system  can  not  resist  temptation  and  often 
craves  for  stimulation  and  excitement.  Alcohol 
predisposes  to  tuberculosis  in  the  child  as  well  as 
in  the  adult,  and  the  prevention  of  child  labor  will 
in  many  instances  prevent  both  alcoholism  and 
tuberculosis. 

Sweatshops,  that  is  to  say  the  manufacture  of 
any  article  in  the  crowded  homes  of  the  poor, 
should  be  absolutely  prohibited  everywhere.     In 


WOMAN'S  AND  CHILD  LABOR  215 

my  work  in  the  tenement  homes  I  have  again 
and  again  seen  overcrowded  rooms  used  as  work- 
rooms during  the  day  and  as  bedrooms  at  night, 
and  among  the  workers  I  often  found  more  than 
one  tuberculous  individual  in  the  most  active 
stage  of  the  disease.  When  we  recall  the  numerous 
sources  of  infection  from  close  contact,  do  we  need 
to  wonder  that  tuberculosis  is  most  frequent 
among  the  toilers  in  the  tenements  and  particu- 
larly among  those  who  work  at  home  ? 

The  sanitary  supervision  of  all  factories  with 
reference  to  proper  ventilation,  dust  catchers,  pre- 
vention of  overcrowding,  proper  washroom  and 
toilet  facilities,  must  form  an  important  part  of 
the  legislation  of  any  state  desiring  to  protect  its 
laborers  against  contracting  tuberculosis.  The 
hours  of  work  should  be  regulated  by  law,  so  that 
overwork  and  overstrain  maybe  avoided,  and  thus 
a  predisposing  factor  to  tuberculosis  removed. 
It  might  even  be  wise  to  issue  anti-spitting  regula- 
tions for  factories,  to  compel  the  employers  to 
provide  a  sufficient  number  of  well-kept  cuspi- 
dors, and  to  make  promiscuous  expectorating  on 
floor  and  walls  punishable  by  discharge.  The 
automatic  flushing  spittoons  already  shown  in 
Figs.  41  and  42  and  the  Proedohl's  spittoon  of 
iron  (Fig.  55)  seem  to  be  particularly  well  adapted 
for  sputum  receptacles  in  factories,  workshops,  etc. 


2i6  TUBERCULOSIS 

Industries  which  are  particularly  dangerous  re- 
garding tuberculosis,  should  be  made  the  subject 
of  special  study  on  the  part  of  the  legislators  in 
order  to  minimize,  as  far  as  possible,  the  danger 
to  the  workmen  and  the  hardship  to  the  manu- 
facturer. 

In  Chapters  II  and  VI  we  have  spoken  of  the 
prevention  of  tuberculosis  through  the  milk  and 
meat  supply.  It  is  necessary  here  to  say  a  few 
words  on  the  duties  of  state  legislation  regarding 
bovine  tuberculosis.  Every  state  should  have 
bovine  laws  so  framed  that  by  their  enforcement 
no  injustice  can  be  done  to  farmer,  consumer,  or 
resident  in  a  neighboring  state.  When,  with  the 
aid  of  tuberculin  or  other  tests,  cattle  are  found 
tuberculous  to  a  degree  that  their  destruction 
becomes  necessary,  it  should  be  the  duty  of  the 
state  to  compensate  the  farmer  for  his  loss.  No 
tuberculous  meat  should  be  allowed  to  reach  the 
market.  There  should  be  reciprocity  between 
neighboring  states;  for  if  one  state  has  good 
bovine  laws,  destroys  the  cattle  and  compensates 
the  owner,  and  the  other  state  has  no  bovine  laws 
at  all,  this  will  at  times  tempt  unscrupulous 
individuals,  under  the  shadow  of  the  night,  to 
drive  their  tuberculous  cattle  into  the  neigh- 
boring state  with  good  bovine  laws  where  they 
will  be  paid  for.     When  all  states  will  have  these 


GOVERNMENT  SANATORIA  217 

laws,  such  unscrupulous  conduct  will  not  be 
possible. 

Our  federal  government  has  also  its  part  to 
play  in  the  combat  of  tuberculosis.  The  one  class 
of  men  in  the  United  States  government  employ 
among  whom  tuberculosis  is  relatively  rare,  is  the 
army  and,  perhaps,  also  the  navy.  This  is  due, 
on  the  one  hand,  to  the  fact  that  men  of  weak 
constitution  are  not  accepted  for  mihtary  service, 
and  on  the  other,  to  the  thorough  training  of  our 
military  and  naval  physicians,  who  examine  every 
candidate  for  the  army  and  navy  most  carefully 
for  the  possible  existence  of  tuberculosis,  and  thus 
avoid  sources  of  infection  in  the  military  or  naval 
service.  When  a  soldier  or  sailor  does  develop 
tuberculosis  during  his  service,  his  condition,  as 
a  rule,  is  readily  discovered;  he  is  isolated  and 
treated  and  usually  transferred  to  one  of  the  exist- 
ing federal  sanatoria,  situated  at  Fort  Stanton,  New 
Mexico,  for  the  Marine  Hospital  Service;  at  Fort 
Bayard,  New  Mexico;  and  at  New  Fort  Lyon, 
Colorado,  for  the  army. 

It  would,  nevertheless,  be  an  admirable  thing 
and  helpful  in  the  prevention  of  tuberculosis,  to 
instruct  every  United  States  soldier  and  sailor  in 
the  simple  principles  of  the  prevention  of  tubercu- 
losis. This  would  not  only  be  helpful  to  the  men 
themselves,  but  would  make  them  educational  fag- 


2i8  TUBERCULOSIS 

tors  in  hygiene  when  they  returned  to  civil  hfe  or 
entered  other  spheres  of  federal  activity. 

There  is  also  an  army  of  men  in  the  government 
non-military  services  whose  mortality  from  tu- 
berculosis could  be  vastly  decreased.  I  refer  par- 
ticularly to  the  thousands  of  post-office  employees. 
The  Postmaster-General's  order,  No.  855;  in  the 
Daily  Bulletin, No.  7,966  of  Aprils,  1906,  contains 
the  following: 

Regulations  to  Prevent  the  Spread  of  Tubercu- 
losis IN  Government  Buildings,  Offices,  and 
Workshops. 

1.  All  persons  in  Government  employ  are  positively 

forbidden  to  spit  upon  the  floors. 

2.  Rooms,  hallways,  corridors,  and  lavatories  shall  be 

freely  aired  and  effectually  cleaned  at  least  once  a 
day,  and  not  during  working  hours. 

3.  Spittoons  shall  receive  a  daily  cleansing  with  very 

hot  water  and  when  placed  ready  for  use  must 
contain  a  small  quantity  of  water. 

4.  Dust  must  be  removed  as  completely  as  possible  by 

means  of  dampened  cloths  or  mops.  It  should 
never  be  needlessly  stirred  up  l)y  a  broom  or 
duster,  as  this  practice  only  spreads  the  dust  and 
germs. 

5.  Floors  of  tiling,  brick,  or  stone  must  be  frequently 

scoured  with  soap  and  water. 

6.  The  senior  clerks  in  charge  of  workrooms  will  take 


GOVERNMENT  REGULATIONS  219 

measures  to  secure,  during  working  hours,  the  ad- 
mission of  as  much  fresh  air  and  sunshine  as  the 
conditions  will  permit. 

7.  The  use  of  individual  drinking  glasses  is  recom- 

mended. 

8.  Persons  in  Government  employ  who  suffer  from 

pulmonary  tuberculosis  shall,  when  possible,  be 
separated  from  others  while  at  work. 

9.  Such  persons  will  not  be  permitted  to  use  the  public 

spittoons,  but  must  provide  themselves  with  in- 
dividual sputum  receivers,  preferably  of  easily 
destructible  material,  and  carry  these  with  them 
on  arrival  and  departure.  They  will  be  held 
strictly  responsible  for  the  disposal  and  destruc- 
tion of  their  own  sputum,  so  that  no  other  per- 
son's health  may  be  endangered  therefrom. 

10.  Such   persons   must   provide   their   own   drinking 

glasses,  soap,  and  towels,  and  shall  not  use  those 
provided  for  the  general  use. 

11.  Plainly  printed  notices,  reading  as  follows:  "Do 

Not  Spit  on  the  Floor;  To  Do  So  May 
Spread  Disease,"  shall  be  prominently  posted 
in  rooms,  hallways,  corridors,  and  lavatories  of 
public  buildings. 

These  regulations  as  a  whole  are  excellent,  but 
from  conversations  I  have  had  with  a  number  of 
post-office  employees  and  even  postmasters,  it 
seems  that  there  are  unfortunately  not  enough 
helpers,  such  as  charwomen,  janitors,  and  cleaners, 


22d  TUBERCULOSIS 

to  carry  out  these  admirable  instructions.  The 
floors  are  not  scrubbed  and  cleaned  nearly  often 
enough  when  one  considers  how  many  men  work 
in  these  rooms.  There  should  be  more  workrooms 
in  all  of  our  post-offices  so  that  one  section  can  al- 
ways be  cleaned  without  interference  with  the  work, 
and  in  this  cleaning  and  scrubbing  the  pigeonholes, 
which  are  natural  dust-collectors,  should  not  be 
forgotten.  The  cleaning  should  naturally  be  done 
when  the  smallest  number  of  employees  are  in  the 
office,  and  preferably  always  by  the  pneumatic 
cleaning  process.  The  corridors,  lobbies,  and  other 
portions  of  the  average  post-office  building  to 
which  the  public  has  access,  are  usually  kept  in 
pretty  fair  condition;  but  it  is  not  always  so  with 
the  rooms  in  which  the  men  work  behind  the 
screens. 

There  is  no  government  service  which  touches 
the  people  so  directly  or  to  so  great  an  extent  as 
does  the  postal  service,  and  this  induces  me  to 
speak  of  another  source  of  infection  to  which  too 
little  attention  has  been  paid  heretofore.  There 
is  scarcely  a  citizen  of  this  country  who  does  not 
sooner  or  later  receive  matter  through  the  medium 
of  the  mails.  This  mail  is  conveyed  from  one 
place  to  another  in  receptacles  made  of  canvas; 
these  receptacles  are  used  until  they  become  un- 
patchablc,  but  arc  never  cleaned.     As  these  sacks 


CLEANING  MAIL  BAGS  221 

become  torn,  they  are  sent  to  the  mail-bag  repair 
shop  and  are  patched.  When  in  use  they  are 
more  or  less  heavy  and  are  thrown  from  the  cars 
or  dragged  by  the  cords  over  the  railroad  plat- 
forms and  approaches,  and  also  through  the  ofhce. 
If  a  consumptive  is  on  the  platform  waiting  for 
his  train  and  has  expectorated  before  the  mes- 
senger comes  along  dragging  the  mail  over  the 
platform  in  the  canvas  sack  to  the  car,  this  sputum 
is  wiped  up  by  the  canvas  sack  and  dries,  and  the 
next  time  the  sack  is  thrown  out  or  handled  in  the 
post-ofhce,  the  air  is  impregnated  with  bacilli-laden 
dust.  The  man  handling  the  sack,  sooner  or  later 
has  his  hand  to  his  mustache  or  mouth,  in  ad- 
dition to  being  exposed  to  inhahng  the  infec- 
tious dust. 

It  has  been  said  that  the  mail  is  on  the  inside 
and  the  infection  on  the  outside  of  the  bag,  but 
this  is  begging  the  question.  Eventually,  all  of 
these  sacks  are  rounded  up  in  some  depository 
for  shipment,  and  the  result  is  that  some  nineteen 
sacks  are  folded  and  placed  inside  the  twentieth 
sack  as  a  receptacle.  This  is  the  manner  in  which 
they  are  stored  and  shipped.  If  a  sack  full  of  these 
empties  is  shipped  from  Chicago  to  New  York, 
the  outsides  of  the  nineteen  bags  are  rubbing 
against  the  inside  of  the  twentieth  bag  all  the  way 
to  New  York,  and  the  filth  and  dirt  is  left  inside 


222  TUBERCULOSIS 

this  nventieth  bag,  in  which  mail  is  deposited  at 
New  York  for  delivery  at  some  other  office,  and 
this  mail  rubs  up  against  the  inside  of  the  sack 
and  then  proceeds  to  a  thousand  homes  or  com- 
mercial offices. 

It  would  seem  entirely  practical  to  clean  these 
mail  receptacles  or  sacks.  It  could  be  done  with 
very  little  expense  in  the  following  manner,  which, 
briefly  stated,  is  to  establish  at,  at  least  three 
points,  one  central  and  one  on  each  coast,  deposito- 
ries for  mail  sacks  to  which  they  could  be  sent  to  be 
disinfected  and  cleaned.  There  should  be  a  suf- 
ficient supply  of  equipment  so  that,  for  instance, 
all  sacks  coming  into  New  York,  Chicago,  San 
Francisco,  or  other  selected  points,  could  be  sent 
to  some  place  for  treatment  before  being  used 
again;  and  all  of  those  which,  upon  inspection, 
showed  the  need  of  cleaning  could  be  sent  direct 
to  the  nearest  depository.  A  one-story  structure 
built  along  a  railroad,  where  shipping  facilities 
could  be  provided  and  preferably  where  water- 
power  could  be  obtained,  would  be  required. 
This  building  w^ould  have  at  one  end  a  receiving 
room,  in  which  the  office  for  the  necessary  records 
would  be  situated,  and  the  sacks  would  be  sepa- 
rated according  to  size  and  character  and  trans- 
fered  to  the  next  room,  where  there  should  be 
cylindrical  washing  machines  revolving  in  a  pit. 


CLEANING  MAIL  BAGS  223 

in  which  the  water  could  be  boiled  by  steam  pipes 
and  into  which  and  from  which  it  could  pass  by 
means  of  large  cocks.  Disinfectants  should  be 
used  in  this  water,  and  after  the  bags  had  been 
boiled,  disinfected,  and  washed,  they  could  be  re- 
moved to  the  opposite  side  of  this  room,  adjoining 
which  would  be  a  dry  room;  this  dry  room  would 
have  a  travelling  link  belt  with  hooks  upon  it, 
which  would  pass  through  drums  to  change  its 
direction,  so  that  the  bags  would  go  in  through 
trapdoors  at  one  side  of  the  room,  pass  back  and 
forth  and  out  at  the  further  corner.  Here  they 
could  be  removed  automatically  from  the  hooks, 
dropped  into  a  slide,  and  run  through  a  mangle 
simply  to  smooth  them  out.  From  this  they 
could  be  reassembled  and  stored  in  a  shipping 
room  at  the  farther  end,  from  which  they  could  be 
sent  out  again  for  general  use. 

I  am  indebted  to  a  friend,  who  has  had  a  large 
experience  both  in  post-ofhce  work  and  in  public 
sanitation,  for  a  little  sketch  which  I  take  pleasure 
in  reproducing  here,  showing  how  the  cleaning 
and  disinfection  of  empty  mail  bags  can  be  done 
easily  and  cheaply.    (Fig.  57.) 

This  is,  of  course,  only  intended  as  the  rough 
suggestion  of  a  general  plan,  and  the  details 
would  have  to  be  v/orked  out. 

I  wish  to  say  one  more  word  about  preventing 


224 


TUBERCULOSIS 


D  t~^ 

E  ^ 

Fig.  57. 


Plan  of  Station  for  Cleaning  and  Disinfecting  Post-office 
Mail  Bags. 

the  development  of  tuberculosis  among  our  post- 
office  employees  and  other  men  in  federal  civil 
service.  First  of  all,  a  very  strict  and  careful 
physical  examination  by  a  competent  physician 
should  be  made  of  every  one  who  is  now  an  em- 
ployee in  these  services.  Secondly,  every  applicant 
to  one  of  these  services  should  be  examined,  and 
only  if  found  free  from  tuberculosis  should  he  be 
admitted  to  the  service.  To  each  large  post-office 
should  be  attached  a  physician  to  whom  employees 
might  apply  for  reexamination  at  stated  intervals. 
Should  any  one  be  discovered  to  be  tuberculous, 
he  should  be  at  once  excluded  from  indoor  service 
and  be  placed  under  proper  treatment.  One  of 
the  physician's  duties  should  also  be  to  watch  over 


GOVERNMENT  EMPLOYEES  225 

the  sanitation  of  the  post-office  buildings  and 
workrooms. 

To  make  the  treatment  of  the  government's 
tuberculous  employees  possible,  it  would  be  a  most 
excellent  thing  for  the  United  States  government 
to  have  not  only  a  sanatorium  for  its  consump- 
tive soldiers  and  sailors,  but  also  one  for  its 
faithful  servants  who  contract  tuberculosis  in  the 
non-military  service  of  the  government. 

To  municipal  authorities,  state,  and  federal  au- 
thorities alike,  we  would  finally  recommend  the 
establishment  of  horticultural  and  agricultural 
colonies  and  similar  kinds  of  outdoor  labor  centers 
where  the  relatively  cured  consumptive  could  have 
a  chance,  by  healthful  labor  and  careful  living, 
to  complete  his  cure  or  make  it  more  lasting. 
There  is  to  my  mind  no  greater  fallacy  and  no 
greater  waste  of  money  than  for  the  state  or  mu- 
nicipality to  cure  the  tuberculous  poor  who  come 
from  the  most  unhygienic  surroundings  and  most 
unhealthful  occupations,  and  then  to  return  them 
again  to  the  same  unhygienic  environments  or  to 
the  same  unhealthful  occupation  from  which  they 
came.  In  my  humble  opinion,  it  would  even  pay 
to  have  a  municipal  or  state  labor  bureau,  by  the 
aid  of  which  suitable  occupations  could  be  found 
for  individuals  leaving  the  sanatorium. 

I  must  not  forget  in  this  chapter  to  mention  one 


226  TUBERCULOSIS 

more  matter  which  is  most  important  in  the  cru- 
sade against  tuberculosis.      Our  statesmen  should 
do  all  in  their  power  to  stem  the  ever  rising  tide  of 
emigration  from  village  to  city.    We  should  strive 
to  reverse   this  tendency.     The  interests  of  the 
farmer  should  be  considered  so  that  farming  will 
have  more  attraction  to  the  rising  generation  than 
it  has  had  in  the  last  few  decades.    If  philanthro- 
pists can  be  interested  in  this  work,  all  the  better; 
but  the  state  should  be  rich  enough  in  itself  to 
endow  institutions  for  instruction  in  scientific  and 
profitable  agriculture,  and  also  to  provide  health- 
ful amusements,  good  libraries,  and  other  educa- 
tional institutions  in  country  districts,  thus  making 
living  outside  of  large  cities  more  interesting  and 
attractive  to  young  people;  in  short,  the  love  of 
nature  and  life  in  the  open  air  should  be  more  cul- 
tivated.    In  the  proportion  in  which  this  is  done, 
tuberculosis  will  decrease. 

The  creation  of  schools  of  forestry  in  connection 
with  the  preservation  and  cultivation  of  forests  in 
many  states  where  a  wasteful  destruction. of  trees 
is  now  carried  on,  would  give  useful  and  healthful 
employment  to  numbers  of  people,  as  well  as  ren- 
der the  region  more  healthful.  It  would  offer 
attractive  careers  to  young  men  seeking  to  over- 
come hereditary  or  accjuired  tendencies  to  tuber- 
culous diseases. 


GOVERNMENT  METHODS  227 

To  combat  tuberculosis  successfully  in  a  coun- 
try like  our  own,  there  must  be  cooperation  of 
municipal,  state,  and  federal  governments.  Such 
cooperation  exists  in  most  European  countries 
where  there  is  either  a  Department  of  Public 
Health  with  a  minister  at  its  head  or  a  bureau 
equivalent  in  rank,  as  for  example  "das  Reichs- 
gesundheitsamt "  in  Germany  and  the  "Conseil 
Superieur  de  Sante  Pubhque"  of  France.  It  is 
most  gratifying  to  learn  that  the  Hon.  Wm.  H. 
Taft,  President  of  the  United  States,  has  recently 
pronounced  himself  distinctly  in  favor  of  such  a 
department  or  federal  bureau  of  health.  Shortly 
after  his  inauguration  last  March,  one  of  his  first 
actions  was  to  approach  the  Surgeon-General  of 
the  Public  Health  and  Marine  Hospital  Service  as 
to  the  advisabihty  of  establishing,  in  Hne  with  prac- 
tical government  methods,  a  new  Public  Health 
Bureau,  as  suggested  to  him  by  the  Committee  of 
One  Hundred,  the  American  Health  League,  and 
the  American  Medical  Association.  Thus,  it  seems 
that  President  Taft  has  realized  that  to  combat 
tuberculosis  successfully  requires  not  only  well- 
trained  physicians  and  an  intelligent  people,  but 
also  a  wise  government  taking  an  active  part  in 
the  work. 


CHAPTER  VIII 

WHAT  EMPLOYERS  OF  EVERY  KIND  CAN  DO  TO 
DIMINISH  TUBERCULOSIS  AMONG  THE  MEN  AND 
WOMEN  WORKING  EOR  THEM 

Factory  hygiene  and  sanitation  should  not  be 
merely  a  matter  attended  to  because  of  the  laws 
enacted  and  enforced  by  the  state  or  city.  Fac- 
tory inspectors,  employers  of  large  forces  of  men 
and  women,  factory  owners  and  managers,  store- 
keepers, and  all  others  having  men  and  women  in 
their  employ,  should  realize  that  the  better  the  hy- 
gienic conditions  are  which  environ  their  employ- 
ees, the  better  the  work  will  be  done  and  the  fewer 
will  be  the  absences  on  account  of  illness.  The 
employer  who  has  the  welfare  of  his  employees  at 
heart  can  do  an  infinite  amount  of  good  in  the  pre- 
vention of  fb'sease,  and  particularly  of  tuberculosis. 
To  this  end,  he  shoukl  begin  by  seeing  that  the 
lighting,  heating,  and  ventilation  are  as  perfect  as 
they  can  possibly  be  in  factory,  workshop,  ofiice, 
store,  or  kitchen,  and  the  amount  of  dust  and  odors 
in  all  such  places  should  be  reduced  as  much  as 

possible.     Spitting  regulations  should  be  enforced 

228 


FACTORY  AND  OFFICE  HYGIENE         229 

and  suitable  well-kept  cuspidors  placed  through- 
out the  buildings. 

In  the  preceding  chapters  I  have  spoken  of 
factory  hygiene,  but  we  must  not  forget  that  be- 
sides the  factory  workers  there  are  thousands  of 
employees  and  clerks  in  offices  and  stores,  who  are 
often  exposed  to  the  inhalations  of  vitiated  air 
and  dust  not  infrequently  mingled  with  disease- 
producing  organisms,  among  which  those  of 
tuberculosis  are  almost  sure  to  be  found. 

Often  in  the  offices  of  the  wealthiest  corporations, 
bankers,  and  great  commercial  concerns,  the  air 
is  about  as  foul  and  vitiated  as  it  can  well  be. 
These  conditions  are,  no  doubt,  permitted  to  exist 
through  ignorance  of  the  importance  of  fresh  air. 
It  is  interesting  to  observe  that  the  heads  of  the 
offices  expose  themselves  to  the  same  unhygienic 
environments  as  their  employees.  They  seem  to 
forget  that  a  glass  wall,  a  few  feet  in  height, 
does  not  prevent  them  from  breathing  the  air 
exhaled  and  used  up  by  their  employees.  If 
the  artificial  ventilation  is  not  sufficiently  per- 
fect to  assure  fresh,  good  air  all  the  time  in  these 
offices,  the  only  remedy  is  to  open  the  windows  fre- 
quently to  change  the  air,  and  this  change  of  air 
should  be  made  even  when  the  weather  is  cold. 
Wherever  possible,  the  lighting  of  any  office  or  fac- 
tory, workshop,  store,  or  even  kitchen  should  be  by 


230  TUBERCULOSIS 

electricity.  Gas  consumes  the  oxygen  needed  for 
the  human  beings,  and  unless  there  is  a  constant 
supply  of  fresh  air  in  any  room  lighted  by  gas  and 
filled  with  human  beings,  the  atmosphere  is  bound 
to  be  deficient  in  oxygen  and  with  carbonic  acid 
gas  in  excess.  Toilet  and  washing  facilities  should 
be  perfect  everywhere,  but  particularly  so  where  a 
great  many  people  are  employed. 

There  are  industries  in  which,  during  the  hours 
of  work,  laborers  are  often  exposed  to  a  high 
temperature.  In  some  occupations  the  laborers 
work  half  stripped,  as  otherwise  they  could  not 
stand  the  heat.  In  such  cases  especial  facilities 
should  be  provided  for  the  laborers  to  cool  off 
gradually  in  order  to  avoid  the  often  serious  con- 
sequences of  going  from  an  overheated  room  half 
nude  into  a  cold  apartment  to  dress.  In  industries 
connected  with  a  great  deal  of  dust,  special  dust- 
collectors  should  be  installed  and,  if  necessary,  la- 
borers should  be  provided  with  respiratory  masks. 

These  precautions  will  do  much  for  the  pre- 
vention of  the  predisposing  factors  to  tuberculosis, 
for  as  it  has  been  said  before,  fresh,  pure  air  and 
cleanliness  are  powerful  agents  in  protecting  an 
individual  from  the  attacks  of  disease. 

We  have  already  spoken  of  the  anti-spitting 
regulations  and  the  needs  of  their  enforcement  in 
order  to  diminish  the  direct  sources  of  infection 


FACTORY  AND  OFFICE  HYGIENE        231 

which  heretofore  have  caused  so  many  employees 
in  factories,  workshops,  stores,  and  ofhces  to  be- 
come victims  of  consumption  from  the  dissemina- 
tion of  bacilh  through  indiscriminate  expectorating. 
To  such  ordinances  there  should  be  added  a  rule 
something  like  this:  It  is  just  as  important  to 
hold  a  hand  or  handkerchief  before  the  mouth 
when  coughing  as  it  is  to  expectorate  into  a  proper 
receptacle.  This  can  not  be  mentioned  too  often, 
for  the  possibility  of  droplet  infection  has  been 
much  overlooked,  and  because  of  its  insidious- 
ness  it  is  all  the  more  dangerous  when  men  work 
close  together  indoors. 

Another  important  step  to  prevent  direct  infec- 
tion from  tuberculosis,  here  as  elsewhere,  is  the 
careful  examination  of  every  employee  entering 
a  workshop,  factory,  store,  office,  etc..  By  this 
method  a  patient  afflicted  with  an  open  tuber- 
culosis, that  is  to  say,  with  the  disease  in  a  stage 
in  which  he  needs  treatment  and  care  and  in  which, 
unless  he  receives  treatmient  and  care  he  may  con- 
stitute a  source  of  infection  to  others,  may  be  ex- 
cluded. This  exclusion  is,  of  course,  particularly 
necessary  when  the  work  which  is  expected  of  the 
patient  is  arduous  and  when  he  is  placed  in  close 
contact  with  other  workmen. 

To  prevent  tuberculosis  in  these  places  w^here 
many  people  work,  it  does  not  suffice  merely  to 


232  TUBERCULOSIS 

examine  the  patient  on  entering  the  employment; 
it  will  also  be  necessary  to  reexamine  all  employees 
at  least  once,  but,  better  yet,  twice  a  year  in  order 
to  ascertain  whether  tuberculosis  may  not  have 
developed  since  their  entrance.  Besides  this,  the 
employees  should  know  that  they  have  the  privilege 
to  call  at  any  time  on  the  factory  physician  for  ex- 
amination, if  a  suspicious  symptom  should  show 
itself. 

It  will  be  in  the  interest  of  the  employer  to  engage 
a  physician  to  enlighten  the  employees  by  an 
occasional  lecture  on  the  subject  of  tuberculosis; 
to  teach  them  what  they  should  know  about  it  and 
how  they  can  help  to  diminish  the  spread  of  the 
disease.  But  the  responsibility  of  the  employer 
regarding  tuberculosis  does  not  end  here.  It  will 
be  necessary  also  for  him  to  see  that,  when  one 
of  his  employees  is  found  to  be  tuberculous,  he 
receives  immediate  care  and  treatment  at  home 
or  in  a  special  institution.  The  benevolent  em- 
ployer who  has  the  welfare  of  his  employees  at 
heart,  will  not  even  content  himself  with  that,  but 
will  also  sec  that  his  employee's  family,  now  de- 
prived of  its  breadwinner,  will  not  be  in  want. 
Whether  the  employee,  if  found  tuberculous,  can 
be  treated  at  home  or  must  be  sent  to  a  special 
institution,  will  depend  on  circumstances.  In  some 
instances  it  may  be  advisable  for  the  patient,  when 


MINERS  233 

cured,  not  to  return  to  the  same  occupation,  but 
to  seek  outdoor  employment  or  lighter  labor. 

Proper  sanitation  and  proper  safety  devices  in 
the  mines  and  collieries  where  so  many  people 
are  engaged  will  prevent  tuberculosis  and  other 
diseases.  The  inhalation  of  coal  dust  in  mines 
can  be  minimized  by  proper  ventilation,  and  by 
judicious  division  of  labor  the  health  of  the  miners 
can  be  improved,  if  the  owner  will  only  do  his  duty 
in  this  respect. 

I  have  often  wondered  why  it  is  that  we  have  in 
our  large  cities  so  many  tuberculous  servants. 
Many  of  these  were  born  in  foreign  countries 
and  nearly  all,  even  those  born  in  this  country, 
had  never  been  ill  before  they  came  to  the  city; 
but  while  serving  as  domestics  they  contracted 
tuberculosis.  The  reason  for  the  frequency  of 
tuberculosis  among  servants  in  the  city  must  be 
primarily  ascribed  to  the  very  often  unhygienic 
methods  of  housing  them.  The  majority  of  them 
come  from  rural  districts  and  have  been  accus- 
tomed to  fresh  air  and  outdoor  life.  In  the  city 
they  are  often  cooped  up  in  the  smallest  room  of 
the  fiat  which  itself  receives  neither  too  much  sun- 
shine or  air.  In  winter  the  room  is  often  over- 
heated, or  else  it  is  without  heat  at  all. 

It  would  seem  as  if  it  w^re  in  the  powxr  of 
every  one  employing  servants  to  see  that  the  con- 


234  TUBERCULOSIS 

ditions  productive  of  tuberculosis  are  done  away 
with. 

Telephone  operators,  who  are  principally  women, 
belong  to  a  class  of  employees  whose  occupation 
demands  confinement  indoors,  and  close  confine- 
ment, as  has  been  pointed  out,  not  infrequently 
predisposes  to  tuberculosis.  The  remedy  for  this 
lies,  of  course,  in  ventilation  and  care  from  infec- 
tion. The  air  in  the  operating  room  should  be 
kept  cool  and  fresh  even  in  winter.  The  girls 
should  be  warmly  clad  and  should  work  in  a  good 
deal  lower  temperature  than  is  usually  to  be  found 
in  these  rooms.  Work  should  be  divided  so  that 
the  physical  strain  is  not  too  great.  All  operators, 
male  or  female,  should  be  examined  for  tubercu- 
losis and  periodically  reexamined.  The  transmit- 
ter should  be  washed  out  with  some  antiseptic 
solution  every  time  a  man  or  woman  goes  on  duty, 
thus  there  will  be  an  assurance  that  whatever  germs 
may  have  been  expelled,  be  they  grippe  or  tu- 
bercle bacilli,  pneumonia  cocci  or  other  disease- 
producing  microorganisms,  will  not  gain  entrance 
into  their  systems.  But  the  telephone  company 
also  owes  to  its  patrons  the  duty  of  protecting  them 
against  possible  infection  from  the  use  of  the  pub- 
lic telephone.  A  simple  device,  as  illustrated  in 
the  accompanying  picture  (Fig.  58),  would  suffice 
for  all  practical  purposes  to  protect  from  possible 


HYGIENIC  TELEPHONE  TRANSMITTER    235 


infection.  A  roll  of  thin  paper  is  attached  to  the 
telephone  as  a  protective  screen,  so  that  the  end 
passes  over  the  transmitter.  After  or  before  each 
time  the  telephone  is  used, 
the  paper  is  pulled  down  so 
that  a  fresh  portion  covers 
the  mouthpiece,  and  the  end 
torn  off.  The  torn-off  pieces 
should  be  collected  in  a  special 
receiver  and  burned  at  night. 
The  thin  piece  of  paper  does 
not  interfere  with  the  trans- 
mission of  the  voice.  Similar 
arrangements  are  already  in  fig.  58.  Hygienic  De- 
use   in  some  of  the  Western      ^'^^^    ^°^     Telephone 

.        .  ,  Transmitter. 

health  resorts. 

There  are,  perhaps,  no  employers  or  corpora- 
tions which  are  responsible  for  the  safety  and 
health  of  so  many  people  as  the  railroad  compa- 
nies. What  has  been  said  in  the  preceding  para- 
graphs on  the  duty  of  employers  and  employees, 
on  the  sanitation  of  workshops,  on  the  examina- 
tion and  reexamination  of  employees  for  tubercu- 
losis, and  on  taking  care  of  those  who  may  have 
developed  or  contracted  the  disease  while  in  their 
employ,  certainly  applies  most  strongly  to  railroad 
corporations.  But  also,  because  of  the  difficulty  of 
the  service,  managers  of  railroads  should  bear  in 


^36  TUBERCULOSIS 

mind  that  physical  oven\^ork  and  overstrain  not 
only  lead  often  to  serious  railroad  accidents,  but 
that  individual  employees  exposed  to  constant 
overw^ork  or  overstrain  more  readily  contract 
tuberculosis  than  other  individuals. 

Besides  the  duty  of  an  employer  toward  his  em- 
ployees regarding  their  health,  a  railroad  company 
has  an  equally  great  responsibility  not  only  regard- 
ing the  safety,  but  also  the  health  of  its  patrons, 
^luch  has  been  done  for  the  sanitation  of  our 
railroad  coaches  and  sleeping  cars,  but  much  more 
needs  to  be  done.  The  ventilation  in  all  these 
conveyances  can  still  be  improved;  and  it  is  an 
unfortunate  fact  that  in  the  smoking  compart- 
ments, except  of  the  first  class,  there  are  no  spit- 
toons. Usually  in  the  smoking  cars  or  compart- 
ments of  the  second  class,  people  spit  where  they 
please.  Some  companies  have  placed  anti-spitting 
signs  in  the  ordinary  day  coaches,  but  they  have 
failed  to  supply  cuspidors  for  those  who  will  spit. 

A  thorough  cleaning  and  airing  of  all  the 
coaches  after  each  trip,  and  on  long  trips  at  least 
every  six  hours,  would  certainly  render  these 
coaches  more  sanitary.  What  has  been  said  of 
the  day  coaches  applies  also  to  the  parlor  cars,  and 
particularly  to  the  Pullman  cars  which  are  often 
used  by  consumptive  travellers.  The  spittoons 
which  one  fmds  in  the  Pullman  cars,  while  almost 


DUTIES  OF  RAILROAD  CORPORATIONS    237 

always  neat  and  clean  on  the  outside,  never  con- 
tain any  water,  and  the  sputum  has  an  excellent 
chance  to  dry  in  the  flat  cuspidors.  The  danger 
from  dried  sputum  has  been  dwelt  upon  enough 
in  the  preceding  pages  to  need  no  further  mention. 

Consumptive  travellers  going  from  one  place 
to  another  in  search  of  health  are  quite  careful 
as  a  rule ;  still,  I  wonder  if  it  would  not  be  a  good 
practice  to  oblige  every  Pullman  car  conductor 
or  porter  to  report  to  the  proper  authorities  when 
they  have  had  a  consumptive  among  their  passen- 
gers, so  that  the  car  may  be  disinfected  with  for- 
maldehyde gas  before  it  is  used  again.  On  certain 
roads  where  it  is  well  known  that  consumptives 
travel  a  great  deal,  every  car  should  be  disinfected 
on  the  arrival  at  its  final  destination.  I  have  often 
thought  it  would  be  a  good  thing  and  would  pay 
such  companies  to  have  special  ambulance  cars 
for  the  transportation  of  consumptives  to  and  from 
health  resorts. 

I  must  not  leave  the  subject  of  railroad  hygiene 
without  speaking  of  one  of  the  most  annoying  and 
unsanitary  practices.  I  refer  to  the  Pullman  por- 
ters' habit  of  dusting  the  garments  of  passengers 
leaving  the  car,  in  the  faces  of  those  remaining. 
The  windows  are,  of  course,  closed.  This  prac- 
tice, besides  being  a  nuisance,  must  be  considered 
unsanitary  and  dangerous.    There  can  be  no  ob- 


238  TUBERCULOSIS 

jection  to  the  porter  brushing  a  passenger  in  the 
vestibule,  but  I  repeat  most  emphatically  that 
brushing  the  garments  which  the  traveller  wears — 
his  overcoat,  hat,  and  even  his  valise — in  the  midst 
of  a  car  crowded  with  passengers  and  with  the  win- 
dows closed,  I  consider  to  be  a  practice  which  tends 
to  propagate  diseases  of  the  respiratory  organs. 

The  railroad  companies  should  pay  careful  at- 
tention, as  has  been  often  mentioned,  to  pro- 
viding properly  ventilated  office  rooms  for  their 
employees ;  and  telephone  and  telegraph  companies 
should  not  forget  that  the  same  duty  devolves  upon 
them.  The  best  possible  ventilation  and  the  best 
possible  method  of  lighting  and  heating  these 
offices  will  assure  less  indisposition,  better  work, 
and  fewer  cases  of  tuberculosis,  which  are  alto- 
gether too  frequent  among  telephone  and  tele- 
graph operators. 

The  farmer  has  an  opportunity  for  preventing 
tuberculosis  in  more  than  one  direction.  He  can 
prevent  a  predisposition  by  having  his  own  home 
and  the  sleeping  and  living  apartments  of  his 
help  properly  ventilated.  It  is  astonishing  how 
little  people  living  in  the  country,  and  particularly 
farmers,  make  use  in  their  houses  of  the  good, 
pure  air  which  is  at  their  very  door.  For  a  farmer 
to  overwork  a  farm  hand  and  not  provide  him 
with  sufficiently  good  food  and  also,  which  happens 


TUBERCULOSIS  IN  ANIMALS  239 

not  infrequently,  to  deprive  his  own  family  of  the 
best  products  of  his  farm,  is  as  foolish  and  as 
uneconomic  in  the  end  as  anything  can  be. 

To  help  in  the  direct  prevention  of  tuberculosis, 
the  farmer  can  familiarize  himself  with  the  few 
necessary  facts  regarding  the  modes  of  infection 
in  man  on  the  one  hand,  and  on  the  other,  can 
study  and  practice  carefully  what  is  necessary  for 
the  prevention  of  tuberculosis  among  cattle. 

While  it  is  beyond  the  scope  of  this  book  to 
speak  in  detail  of  the  prevention  of  tuberculosis 
in  cattle  and  other  domestic  animals,  I  will,  at 
least,  point  out  the  essentials  with  which  the  farmer 
should  be  familiar  regarding  the  subject.  In 
animals  as  well  as  in  man,  the  direct  cause  of  this 
disease  is  the  tubercle  bacillus.  Bovine  tubercu- 
losis is  prevalent  in  nearly  every  country.  The 
symptoms  of  the  disease  are  much  like  those  in 
man.  They  begin  with  relatively  shght  func- 
tional disturbances.  The  way  the  germ  of  tuber- 
culosis is  transmitted  from  animals  to  men  has 
already  been  explained.  A  tuberculous  farm  hand 
or  anybody  else  expectorating  on  the  meadows 
over  which  cattle  graze,  a  tuberculous  individual 
expectorating  in  the  stable  where  cattle  are  housed, 
may  give  the  disease  to  the  animals.  The  point 
has  been  disputed,  but  it  is  now  generally  conceded 
and  has  been  shown  experimentally  that  the  trans- 


240  TUBERCULOSIS 

mission  of  tuberculosis  from  animals  to  men  and 
men  to  animals  can  take  place.  Although  the 
bacillus  is  not  identically  the  same,  the  one  of  the 
bovine  type  may  adapt  itself  to  thrive  in  the  human 
system,  and  vice  versa.  The  contagion,  or  rather 
the  propagation,  of  the  disease  among  animals 
takes  place  in  various  ways:  First,  by  drop  in- 
fection, that  is  to  say,  little  particles  which  are  ex- 
pelled during  the  seemingly  dry  cough,  the  same 
as  in  man.  Secondly,  by  the  discharge  from  the 
lungs  or  also  from  the  glands  of  the  throat,  coughed 
up  in  the  ordinary  way.  Thirdly,  through  tubercu- 
lous matter  coming  from  the  bowels.  Fourthly, 
through  secretions  coming  from  the  sexual  organs 
(vagina  and  uterus).  Fifthly,  through  the  milk 
if  the  udder  is  tuberculous,  or  if  the  whole  body 
of  the  animal  is  invaded  by  the  disease.  Finally, 
the  disease  may  be  directly  transmitted  from  the 
tuberculous  cow  to  the  calf. 

As  to  the  frequency  of  the  various  ways  in 
which  the  contagion  takes  place  and  the  best 
methods  of  prevention,  the  author  does  not  believe 
that  he  can  do  better  than  to  refer  those  interested 
in  this  important  subject  to  the  Bureau  of  Animal 
Industry  in  Washington,  which  gratuitously  sends 
out  literature  giving  explicit  directions  as  to  stable 
hygiene,  testing  cattle  for  tuberculosis,  removal 
and  disposal  of  diseased  animals,  disinfection,  and 


TUBERCULOSIS  IN  ANIMALS  241 

other  preventive  measures.  It  may,  however,  be 
well  to  explain  here  what  is  meant  by  testing 
cattle  for  tuberculosis.  This  is  done  with  the  aid 
of  a  substance  known  as  tuberculin.  The  process 
of  manufacturing  this  substance  was  discovered 
by  Professor  Robert  Koch.  Tuberculin  is  used 
principally  for  the  purpose  of  diagnosing  tuber- 
culous diseases  in  man  or  beast,  and  in  certain 
cases  it  is  employed  as  a  remedial  agent.  It  is  a 
fluid  made  from  cultures  of  the  germs  of  tuber- 
culosis, but  it  does  not  contain  either  the  dead 
or  living  germs.  It  is  sterilized  by  heating,  thus 
killing  the  germs,  and  filtered  through  porcelain, 
so  that  after  they  are  destroyed  they  are  com- 
pletely removed  from  the  fluid. 

In  making  the  test  in  cattle,  it  is  necessary  to 
determine  the  normal  temperature  of  the  animal, 
and  then  inject  a  small  quantity  of  the  tuberculin. 
If  the  animal  has  tuberculosis,  its  temperature 
will  rise  within  from  eight  to  sixteen  hours  after 
the  injection,  but  it  does  not  suffer  from  tuber- 
culosis, if  the  temperature  is  not  influenced. 

The  tuberculin  test  should  always  be  applied 
by  a  competent  veterinarian,  and  then  no  danger 
will  arise  to  the  animals,  for,  when  properly  ap- 
plied, the  healthy  animal  is  never  affected  by  it. 

Of  course,  there  are  conditions  in  animals,  as 
there  are  in  man,  which  predispose  to  the  disease 


24^  TUBERCULOSIS 

The  breed,  as  well  as  the  conditions  under  which 
an  animal  is  compelled  to  live,  determines  its  sus- 
ceptibility. We  believe  it  to  be  perfectly  safe  to 
say  that  the  suggestions  made  regarding  the  pre- 
vention of  tuberculosis  in  man  are  also  applicable 
to  animals.  Light,  air,  cleanliness,  proper  food, 
and  sufficient  exercise  are  essential  in  combating 
tuberculosis  in  the  bovine  race.  After  a  herd  has 
been  freed  from  its  tuberculous  members  and  a 
strict  stable  hygiene  has  been  instituted  allowing 
plenty  of  room  for  every  animal,  there  will  be 
little  danger  of  a  new  outbreak  of  the  disease. 

Tuberculosis  among  swine  is  not  so  rare  as  is 
usually  assumed.  While  the  disease  among  cows 
may  not  always  be  recognized  by  the  loss  of  fat 
and  general  bad  appearance  (for  even  tubercu- 
lous cattle  can  be  fatted),  in  swine  tuberculosis 
manifests  itself  at  a  very  early  date  by  a  marked 
emaciation.  Very  often  these  swine  are  then 
quickly  slaughtered  and  the  meat  made  into 
sausages.  That  through  such  procedures  the 
health  of  the  consumers  is  endangered  is  evident, 
especially  when  one  considers  that  many  kinds 
of  sausages  are  eaten  without  being  cooked. 
Tuberculosis  among  young  swine  manifests  itself 
most  frequently  in  the  form  of  intestinal  troubles. 
The  main  symptoms  of  the  disease  are  the  loss  of 
flesh  and  bad  appearance  already  mentioned,  a 


TUBERCULOSIS  IN  ANIMALS  243 

pale  mucous  membrane — that  is  to  say,  the  inner 
lining  of  the  mouth  loses  its  reddish  color — a 
marked  diarrhoea,  flatulency,  and  discharge  of 
gases.  If  there  is  tuberculosis  of  the  lungs,  cough 
and  vomiting  are  additional  symptoms.  In  both 
forms  of  tuberculosis  a  swelling  of  the  glands 
around  the  neck  is  often  observed.  When  these 
animals  are  slaughtered,  one  can  see  little  tubercles 
or  elevations  and  ulcerations  along  the  inner  walls 
of  the  guts,  and  on  the  surface  of  the  lungs.  As 
soon  as  the  disease  is  discovered  among  the  ani- 
mals, the  sick  swine  should  be  separated  from  the 
healthy  ones.  A  veterinarian  should  then  be  con- 
sulted, who  will  give  directions  for  the  destruc- 
tion of  the  tuberculous  meat  and  the  disinfection 
of  the  sties. 

The  prevention  of  tuberculosis  among  swine  is 
not  so  diflicult  when  one  thinks  of  the  causes  of 
the  disease.  A  sucking  pig  can  be  infected  by  a 
tuberculous  sow.  The  most  frequent  source  of 
tuberculosis  among  hogs,  however,  comes  from 
feeding  them  on  skimmed  milk  and  other  dairy 
products  from  tuberculous  cows.  A  few  cases  are 
also  known  where  hogs  became  tuberculous  from 
eating  the  expectoration  of  consumptives. 

Tuberculous  of  horses  is  rare  and  diflicult  for 
a  layman  to  recognize.  When  a  horse  with  a 
seemingly  good  appetite  has  a  bad  appearance 


244  TUBERCULOSIS 

and  loses  flesh,  tires  easily,  and  is  short  of  breath, 
one  should  think  of  tuberculosis.  jMuch  urinat- 
ing and  a  high  temperature  (fever)  are  additional 
symptoms  of  tuberculosis  in  horses.  When  such 
conditions  are  discovered,  it  is,  of  course,  self- 
evident  that  the  animal  should  be  isolated  until 
the  veterinarian  arrives. 

Tuberculosis  among  goats  is  extremely  rare. 
In  the  few  cases  which  have  been  recorded  the 
origin  of  the  disease  could  be  traced  to  the  in- 
gestion of  milk  from  tuberculous  cows.  Parrots 
and  dogs  take  the  disease  when  living  with  con- 
sumptive people,  and  the  infection  probably  takes 
place  through  ingesting  and  inhaling  infectious 
substances  and  very  often  through  kissing. 

Not  only  tuberculosis,  but  diphtheria  and 
other  diseases  can  be  and  have  been  transmitted 
through  kissing  cats  and  dogs.  Such  habits  should 
be  discouraged,  and  particularly  in  children. 

Shipbuilders,  shipowners,  and  captains  should 
bear  in  mind  that  the  excessively  crowded  quarters 
to  which  the  average  sailor  is  confined  during  his 
hours  of  rest  and  sleep,  arc  absolutely  detrimental, 
and  even  the  outdoor  life  during  the  hours  of  work 
can  not  counteract  the  deleterious  influence  which 
the  vitiated  air  of  the  forecastle  must  have  on  the 
health  of  the  seaman.  Of  course,  we  are  aware 
that  the  space  given  to  each  individual  on  board 


TOBERCULOSIS  among  sailors  245 

ship  must,  of  necessity,  be  limited;  still  there  can 
be  some  improvement,  and  the  ventilation  can  be 
made  more  perfect.  For  the  very  reason  that 
sailors  have  to  live  in  crowded  quarters  the  danger 
of  infection  on  board  ship  is  very  great.  A  tubercu- 
lous sailor  still  at  work  is  almost  certain  to  infect 
his  comrades.  But  shipboard  is  not  the  only  place 
where  sailors  are  exposed  to  the  disease.  When 
on  shore  they  mostly  frequent  and  sleep  in  houses 
where  the  accommodations  consist  of  bunks  and 
straw,  and  where  sanitation  is  so  neglected  that 
they  are  in  the  greatest  danger  of  contracting  the 
disease.  To  prevent  the  spread  of  infection  among 
sailors  there  is  but  one  remedy,  and  that  is  the 
regular  periodic  examination  of  every  sailor  on 
board  ship,  and  the  exclusion  from  service  of  in- 
dividuals suffering  from  pulmonary  tuberculosis. 
Two  New  Methods  of  Antituberculosis  Educa- 
tion.— Since  the  first  edition  of  this  book  the  fol- 
lowing new  methods  have  been  put  forward  in  the 
antituberculosis  propaganda.  One  of  them,  which 
originated  in  California,  is  to  send  through  the 
State  a  railroad  car  equipped  with  a  complete  min- 
iature tuberculosis  exhibit,  a  demonstrator  accom- 
panying the  car  from  place  to  place.  The  second 
method  is  to  hold  a  U.  S.  National  Tuberculosis 
Sunday.  The  latter  has  been  appointed  for  April 
24,  19 10.  Sermons  on  the  prevention  and  treatment 
of  tuberculosis  are  to  be  preached  to  33,000,000 
churchgoers. 


CHAPTER  IX 

THE  DUTIES  OF  SCHOOL  TEACHERS,  EDUCATORS 
IN  GENERAL,  AND  OF  THE  PUBLIC  PRESS  IN 
THE  COMBAT  OF  TUBERCULOSIS 

The  child  of  to-day  will  be  the  man  of  to-morrow, 
and  during  school  life,  the  time  when  the  growing 
organism  is  most  susceptible  to  good  physical  de- 
velopment and  the  growing  mind  most  receptive 
to  all  kinds  of  teaching  and  example,  it  must  be 
evident  that  much  can  be  done  in  the  prevention 
of  tuberculosis. 

Let  us  first  say  a  word  concerning  school  con- 
struction with  a  view  to  preventing  disease  in 
general  and  with  special  reference  to  tuberculosis. 
The  essentials  for  the  construction  of  a  modern 
school  are  well  known  to  all  sanitarians  and  up- 
to-date  architects.  I  would  suggest  only  a  few 
points.  Where  the  site  or  locality  does  not  permit 
of  having  a  large  playground,  a  roof  garden  which 
can  be  covered  in  winter  is  absolutely  necessary. 
(Fig.  59.)  Instead  of  our  American  windows, 
which  can  only  be  opened  to  one-half  of  their  ex- 
tent, I  would  wish  to  see  in  every  schoolhouse, 

246 


o 

d 

Iz; 

o 

XI 
cj 
CO 


c 

O 

to 

c3 


O 

o 


o 


248  TUBERCULOSIS 

French  windows,  windows  that  shde  into  the  wall, 
or  those  that  turn  on  a  pivot,  all  of  which  make 
possible  twice  as  large  an  opening  as  our  ordi- 
nary windows  do.  Heating  and  general  ventila- 
tion should,  of  course,  be  of  the  most  improved 
kind.  The  walls  and  woodwork  of  schoolrooms 
should  be  plain,  in  order  to  make  the  accumu- 
lation of  dust  virtually  impossible  and  the  clean- 
ing easy.  A  smooth  coat  of  oil  paint  makes  a 
good  surface.  All  corners  should  be  rounded 
off.  The  interior  equipment,  that  is  to  say,  the 
school  furniture,  benches  and  desks,  should  be 
arranged  so  that  they  can  easily  be  moved  or 
folded  together,  and  a  thorough  cleaning  of  the 
floors  made  possible  after  each  daily  session.  It 
goes  without  saying  that  the  drinking-cup  should 
be  replaced  by  the  hygienic  drinking  fountain, 
which  makes  the  use  of  a  cup  unnecessary,  and 
thus  eliminates  one  method  of  transmission  of 
microbic  disease. 

Every  public  school  should  have  a  well-equipped 
gymnasium  and  a  swimming  tank  with  constantly 
running  fresh  or  salt  water,  warmed  to  a  suitable 
temperature  in  winter.  (Fig.  60.)  Each  pupil 
should  be  given  the  opportunity  to  bathe  several 
times  during  the  week.  To  learn  to  swim  should 
be  made  obligatory,  and  every  class  should  be 
supervised    by    a    competent    swimming   master. 


Fig.  6o.     Schoolgirls  Learning  to  Swim  at  Corlear  St.  Public  Bath, 

New  York  City. 


250  TUBERCULOSIS 

Leaving  aside  the  great  hygienic  gain  to  be  de- 
rived from  such  an  installation,  especially  when 
the  pupils  are  recruited  from  homes  where  bath- 
rooms are  rare  and  where  regular  bathing  is  con- 
sidered superfluous,  the  swimming  lessons  will  be 
of  value  to  every  boy  and  girl.  In  case  of  such 
disasters  as  the  Slocum  tragedy  which  some  years 
ago  befell  residents  of  New  York,  there  will  be  a 
much  smaller  loss  of  life. 

There  is  hardly  a  college  in  existence  in  Amer- 
ica where  the  gymnasium  and  the  swimming  tank 
do  not  form  an  important  part  of  the  equipment, 
and  a  college  without  them  ..would  surely  suffer 
in  prestige.  The  public  school  where  the  children 
of  the  masses  receive  their  education  should  not 
be  behind  the  private  college  in  matters  that  ap- 
pertain to  health. 

I  am  convinced  that  the  public  school  which 
has  a  well-equipped  swimming  establishment,  and 
which  makes  regular  bathing  and  instruction  in 
swimming  obligatory  -for  every  pupil,  will  not  only 
have  fewer  cases  of  infectious  and  contagious 
diseases,  particularly  scrofula  and  tuberculosis, 
but  that  the  intellectual  and  moral  status  of  its 
pupils  w^ill  also- be  higher. 

Superintendents  and  principals  of  schools  should 
bear  in  mind  that  judicious  physical  exercises, 
outdoor  life,  and  as  much  fresh  air  as  possible  are 


PREVENTION  IN  CHILDREN  551 

most  essential  for  the  normal  development  of  their 
pupils.  There  is  too  great  a  tendency  in  the 
present  age  to  develop  the  intellect  of  our  children 
to  the  detriment  of  their  physical  welfare.  They 
work  too  much,  they  do  not  play  enough,  and  they 
sleep  too  little.  This  overwork,  because  of  too 
many  school  hours,  too  many  lessons  at  home, 
and  too  much  loss  of  sleep,  is  responsible  for  our 
national  disease,  neurasthenia,  particularly  per- 
ceptible in  the  young.  I  was  deeply  impressed 
recently,  when  reading  the  recommendations  of 
the  committee  which  was  appointed  by  the  French 
government  and  the  city  of  Paris  with  a  view  to 
diminish  tuberculosis  among  the  school  children, 
by  the  fact  that  they  insisted  upon  a  minimum  of 
nine  to  ten  hours  of  sleep ;  only  after  the  age  of  ten 
may  the  hours  of  sleep  be  somewhat  shortened. 
The  duration  of  a  lesson  should  likewise  be  graded 
according  to  the  age  of  a  child,  and  for  small 
children  this  time  should  be  made  shorter  than  is 
now  the  custom.    To  ask  the  child  seven  or  eidit 

o 

years  of  age  to  sit  absolutely  still  for  one  hour  is 
bordering  on  cruelty.  I  have  often  wondered  if  it 
would  not  be  better  to  allow  no  children  to  enter  a 
public  or  private  school  for  regular  attendance 
before  the  age  of  eight.  A  child  predisposed  to 
tuberculosis  should  certainly  never  enter  upon 
school  life  before  its  eighth  year. 


2^2 


TUBERCULOSIS 


\Vhile  all  the  organs  of  a  child  should  be  given 
opportunity  for  full  development,  the  respiratory 
system  should  receive  particular  care  and  attention. 
I  would  suggest  that  breathing  exercises  should 
not  only  be  taken  now  and  then,  but  that  they 
should  form  an  important  item  in  the  curriculum 
of  all  the  schools.  I  do  not  believe  that  there  is 
any  better,  greater,  and  more  efficacious  barrier  to 
becoming  consumptive  than  a  good  pair  of  lungs, 
and  it  would  seem  to  me  that  it  should  not  only 
be  a  great  duty,  but  also  a  great  privilege  and 
pleasure  to  make  strong,  vigorous  men  and  women 
out  of  all  children  attending  school. 

There  are  a  number  of  systems  of  breathing 
exercises  in  vogue  in  schools  and  I  would  not  wish 
to  criticise  any,  but  I  may  be  pardoned  for  recom- 
mending the  following  system  since  during  a  some- 
what extensive  experience  I  have  found  it  the  best 
adapted  for  both  school  children  and  adults  with 
a  view  to  developing  their  chest  capacity.  It  goes 
without  saying  that  these  exercises  should  always 
be  taken  in  fresh,  pure  air,  preferably  outdoors; 
but  if  that  is  not  possible,  always  with  the  windows 
open.  In  school  they  should  be  taken  at  the  begin- 
ning of  the  recess,  and  no  class  should  last  longer 
than  three-quarters  of  an  hour.  These  exercises 
can  be  taken  when  the  child  is  mentally  tired,  but 
never  when  physically  tired.    It  is  better  to  have 


RESPIRATORY  EXERCISES  253 

them  play  afterwards  than  to  take  these  exercises 
when  they  are  tired  out  by  running  or  the  usual 
gymnastics. 

The  teacher  should  strive  to  have  his  pupils 
learn  to  love  these  exercises  as  the  average  boy  or 
girl  loves  general  gymnastics.  The  following  is 
as  concise  a  description  of  my  favorite  exercises 
as  can  be  given  to  enable  one  to  teach  them. 

To  begin  with,  the  pupil  has  to  learn  to  stand 
straight,  assuming  the  position  of  the  military 
"attention,"  heels  together,  body  erect,  and  hands 
on  the  sides.  With  the  mouth  closed,  he  takes  a 
deep  inhalation  (that  is,  breathes  in  all  the  air  pos- 
sible), and  while  doing 
so  raises  the  arms  to  a 

horizontal  position  (Fig.         ■^----  ' 

61),  remains  thus  hold- 
ing the  air  inhaled  for 
four  or  five  seconds,  and 
while  exhaling  (breath- 
ing out)  brings  the  arms 

down  to  the  original  pO-    Fig.  61.    Respiratory  Exercise  A. 

sition.    The  act  of  exhal- 
ing, or  the  expiration,   should  be  a   little  more 
rapid  than  the  act  of  inspiration. 

The  act  of  inhalation  occupies  about  four,  the 
act  of  exhalation  about  three  seconds,  and  as  has 
already  been  said,  the  act  of  retention  of  the  air 


254  TUBERCULOSIS 

about  live  seconds.  The  child  should  be  taught 
to  count  mentally  during  these  three  acts  so  as  to 
be  systematic  about  holding  the  air.  One  can 
move  the  hands  up  and  down  twice,  counting  four, 
and  on  the  fifth  second  begin  to 
lower  the  arms  and  exhale. 

When  the  first  exercise  (A)  is 
thoroughly  mastered  one  may  com- 
mence with  the  second  exercise  (B). 
The  pupil  places  his  hands  one 
above  the  other,  in  front  of  the 
chest,  with  the  fingers  bent.  (Fig. 
Fig.  62.  Respira-  62.)  Thc  amis  and  shouldcrs  make 
lory  Exercise  B.  ^  backward  movcmcnt,  the  hands 
moving,  apart  with  a  motion  as  though  wanting 
to  tear  open  the  chest  (the  fingers  remaining  bent) 
while  he  takes  a  deep  inhalation,  holds  the  breath 
counting  four  by  tapping  the  chest  four  times 
with  both  hands,  and  at  the  fifth  second  he  starts 
to  exhale,  bringing  the  hands  and  forearms  into 
the  position  from  which  they  started.  This  exer- 
cise has  the  advantage  that  it  can  be  taken  in  the 
sitting  position,  or  even  when  lying  down  on  the 
back. 

The  third  exercise  (C)  consists  in  raising  the 
arms  from  the  sides  to  the  horizontal  and  then 
above  the  head  (Fig.  63),  taking  a  deep  inhalation 
during  this  act;  then  bending  backward  as  far  as 


RESPIRATORY  EXERCISES 


255 


Fig.  63.      Respira- 
tors' Exercise  C. 


one  can  and  remaining  in  that  position  four  seconds 

while  retaining  the  air,  counting  the  seconds  by 

moving  the  hands  alternately,  for- 
ward  and  backward,  and   on  the 

fifth  second  one  exhales  gradually 

while   resuming  the  original  posi- 
tion.   During  this  exercise  it  should 

be  borne  in  mind  that  when  the 

arms   are   raised    until   the   hands 

join,  one  should  not  bring  the  arms 

close  to  the  head,  but  rather  form 

a  circle  above  the  head  by  bending 

the  arms  outward  enough  so  that 

the  meeting  of  the  index  fingers  and  thumbs  form 

a  triangle. 

The  fourth  exercise  (D)  is  for  the  purpose  of 
bringing  the  abdominal  muscles  also 
into  play,  or  in  other  words,  com- 
bining abdominal  and  chest  breath- 
ing. To  this  end  one  assumes  an 
erect  position,  like  the  beginning  of 
all  the  exercises,  the  hands  meeting 
in  front,  with  the  little  fingers  and 
the  edge  of  the  palms  touching  the 
abdominal     muscles.      (Fig.    64.) 

Fig.  64.    Respira-  While    taking    a    deep   inspiration 

tory  Exercise  D.  •  i         i  •       i  .       .  • 

raise  the  diaphragm,  concentrating 
all  attention  on  this  act,  and  while  doing  so  move 


-^56 


TUBERCULOSIS 


the  joined  hands  upward,  shding  them  along  the 
thorax  up  to  the  chin,  then  turning  them  and 
continue  to  raise  them  until  they  are  above  the 
head,  as  in  Exercise  C,  Fig.  63.  Remain  bent 
backward  during  the  four  seconds  while  retaining 
the  air,  and  then  exhale,  lowering  the  arms  grad- 
ually to  the  horizontal  and  to  the  original  position 
of  ''attention." 

The  fifth  breathing  or  respiratory  exercise  (E), 
which  may  also  be  called  a  dry  swim,  requires 
more  strength  and  endurance.  It  should  not  be 
undertaken  until  the  others  have 
been  practiced  regularly  several 
times  a  day  for  a  few  weeks,  and 
,  until  an  evident  improvement  in 
P^^  breathing  and  general  well-being 
has  been  observed.  One  takes 
the  usual  military  position  of  '' at- 
tention" and  then  stretches  the 
arms  out  as  if  in  the  act  of  swim- 
ming (Fig.  65),  the  backs  of  the 
hands  touching  each  other.  Dur- 
ing the  inspiration  one  moves  the  arms  outward 
until  they  finally  meet  behind  the  back,  remains 
in  this  position  for  the  usual  four  seconds,  count- 
ing by  moving  the  hands  while  retaining  the 
air,  and  on  the  fifth  second  exhales,  bringing 
the  arms  forward   again  ready  to  start  for   an- 


\ 


Fig.    65.       Respira- 
tory Exercise  E. 


RESPIRATORY  EXERCISES  257 

other  swim;  or  if  this  is  the  end  of  the  dry  swim, 
the  arms  return  to  the  original  position  of  ''at- 
tention." This  somewhat  difficult  exercise  can  be 
facilitated  and  be  made  more  effective  by  rising 
on  the  toes  during  the  act  of  in- 
spiration, and  descending  during 
the  act  of  expiration. 

It  will  be  seen  that  with  the  aid 
of  these  five  respiratory  exercises 
every  muscle  of  the  body,  from  the 
nostril  down  to  the  toes,  is  put  into 
play.  The  face  alone  is  at  rest 
and  can  serve  as  an  indicator  that 

Fig.  66.     Respira- 

the   exercises   are   properly    done ;     tory  Exercise  f. 
for  it  must  be  borne  in  mind  that 
they  should  be  taken  with  the  muscles  not  actu- 
ally in  use,  relaxed,  and  all  unnecessary  contrac- 
tion of  muscles  or  tremor-like  movements  must  be 
avoided. 

Of  course,  when  out  of  doors  one  can  not  always 
take  these  exercises  with  the  movements  of  the 
arms  without  attracting  attention.  Under  such 
conditions  one  assumes  a  position  similar  to  "at- 
tention," raises  the  shoulders,  making  a  rotary 
backward  movement  during  the  act  of  inhaling 
(Fig.  66);  remains  in  this  position,  holding  the 
breath  for  four  seconds  and  then  exhales  while 
moving   the   shoulders   forward    and    downward, 


25S 


TUBERCULOSIS 


assuming  again  the  normal  position.  This  exercise 
(F)  can  be  easily  taken  while  walking,  sitting,  or 
riding  in  the  open  air. 

Young  girls  and  boys,  and  especially  those  who 
are  predisposed  to  consumption,  often  acquire  a 
habit  of  stooping.  To  overcome 
this,  the  following  exercise  (G)  is 
to  be  recommended.  The  child 
makes  his  best  effort  to  stand 
straight,  places  his  hands  on  his 
hips  with  the  thumbs  in  front  and 
then  bends  slowly  backward  as  far 
as  he  can  during  the  act  of  inhaling. 
(Fig.  67.)  He  remains  in  this  posi- 
tion from  four  to  five  seconds  while 
holding  the  breath,  and  then  rises 
again  somewhat  more  rapidly  during  the  act  of 
exhalation,  assuming  the  original  position  with 
hands  on  hips. 

The  following  general  rule  concerning  breath- 
ing exercises  should  always  be  remembered.  Com- 
mence with  the  easier  exercises  (A),  and  do  not 
go  on  to  the  more  difficult  ones  until  the  former 
are  completely  mastered.  Take  from  four  to  six 
respiratory  exercises  (one  of  A,  one  of  B,  one  of  C, 
one  of  D,  or  one  of  E)  or  when  outdoors  simply 
exercise  F,  four  to  six  times  every  half  hour  or 
hour,  or  at  least  four  to  six  times  a  day,  and  on 


Fig.  67.     Respira 
tory  Exercise  G. 


RESPIRATORY  EXERCISES  259 

rising  in  the  morning  and  retiring  at  night.  Con- 
tinue this  practice  until  deep  breathing  has  be- 
come a  natural  habit. 

These  exercises  are  not  intended  for  children 
who  are  already  tuberculous,  and  they  should  be 
taught  gradually  and  according  to  the  strength, 
development,  and  understanding  of  the  child.  I 
believe  them  to  be  of  incalculable  benefit  as  a 
means  of  helping  a  child  to  overcome  a  tubercu- 
lous predisposition;  but  they  are  not  indicated  in 
all  cases.  They  can  do  harm  if  the  child  is  very 
delicate  and  not  judiciously  advised  and  guided 
in  the  gradual  development  of  its  physique  as  a 
whole.  They  will  never  be  harmful  to  the  healthy 
child  unless  grossly  overdone.  Children,  as  a  rule, 
take  kindly  to  these  exercises,  and  their  love  for 
fresh,  pure  air,  and  distaste  for  foul  air  becomes 
very  strongly  developed.  There  should  be  no 
fear  that  in  so-called  flat-chested  children  these 
exercises  can  do  harm.  It  is  in  these  very  cases 
that  breathing  exercises  are  indicated,  for  it  must 
be  remembered  that  in  young  children  the  bony 
structure  yields  to  the  pressure  exercised  from 
within.  Thus,  with  the  aid  of  such  respiratory 
exercises  a  flat  or  hollow-chested  child  can  develop 
into  a  strong,  broad-chested  man  or  woman. 

It  is  for  all  these  reasons  that  I  plead  to  have 
breathing  exercises  made  a  regular  and  frequent 


26o  TUBERCULOSIS 

practice  in  schools,  so  as  to  develop  all  the  children's 
chests  and  bodies  in  general  and  make  their  system 
as  resistant  as  possible  to  the  bacillus  of  tubercu- 
losis. As  I  have  already  mentioned,  it  will  be 
seen  from  the  careful  study  of  the  movements 
described  in  these  exercises,  that  all  the  muscles 
of  the  body  are  exercised,  and  without  any  vio- 
lence. 

Some  children  develop  a  habit  of  drooping  one 
shoulder  or  the  other,  and  gradually  a  distinct 
lateral  curvature  of  the  spine  is  developed.  I  have 
often  wondered  if  the  practice  of  some  school  au- 
thorities or  teachers  of  forcing  the  little  girl  or  boy 
to  carry  a  veritable  load  of  books  every  day  to 
and  from  school,  often  up  three  or  more  flights  of 
stairs,  is  not  a  factor  in  producing  this  unnatural 
and  unhealthy  attitude  of  some  children.  Surely, 
every  municipality  should  be  willing  to  spend 
enough  money  so  that  there  may  be  duplicate 
books — one  set  for  home  and  one  set  for  school 
use — and  thus  the  injudicious  and  often  dangerous 
physical  strain  imposed  upon  the  small  children 
will  be  removed. 

As  an  additional  means  to  develop  the  lungs  of 
children  when  in  school,  we  can  not  too  strongly 
recommend  the  practice  of  frequent  singing  and 
recitation  in  the  open  air.  Singing  and  recitation 
outdoors  have  a  most  beneficial  action  on  the 


OPEN  AIR  SCHOOLS  261 

vocal  organs,  on  the  lungs,  and  on  the  heart,  and 
will  help  much  in  the  development  of  the  chest. 

Modern  schools  should  have  it  a  part  of  their 
curriculum  for  all  children,  according  to  age  and 
understanding,  to  visit  zoological  gardens  and 
nearby  farms,  to  go  on  botanizing  tours  and  ge- 
ological excursions,  and  do  mountain  climbing. 
In  large  cities  where  the  visits  to  a  farm  will  not 
often  be  feasible,  there  should  be  school  farms  in 
or  near  the  city  so  that  they  can  be  visited  by  the 
children  without  too  much  loss  of  time. 

The  accompanying  picture  (Fig.  68)  gives  a 
good  idea  how  the  vacant  lots  of  a  city  may  be 
utilized  for  such  a  purpose. 

When  one  deals  with  the  subject  of  tuberculosis 
in  childhood,  and  particularly  at  the  school  age,  one 
must  not  fail  to  recognize  the  sad  fact  that  many 
pupils  in  the  districts  of  the  poor  become  pre- 
disposed to  tuberculosis  not  only  by  reason  of  the 
general  causes  outlined  in  what  has  preceded,  but 
by  reason  of  particularly  bad  home  hygiene,  over- 
work brought  about  by  child  labor  at  home,  and 
lastly,  by  underfeeding  and  malnutrition.  Of  the 
two  former,  the  home  hygiene  and  the  child  labor 
at  home,  we  have  already  spoken  in  the  preced- 
ing chapters.  Here  we  wish  to  discuss  particu- 
larly what  really  concerns  the  school  authorities. 

Those  who  have  looked  into  the  question,  know 


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LUNCHES  263 

that  many  a  child  has  to  go  to  school  with  a  very- 
inadequate  breakfast  and  at  noon  has  to  content 
itself  with  a  very  meager  lunch — both  meals  not 
sufficient  to  supply  the  want  of  a  growing  organism. 
Much  has  been  written  and  said  on  this  subject. 
Many  pedagogic  authorities  and  philanthropists 
have  urged  the  giving  of  free,  substantial  lunches 
at  noon  time.  The  opponents  of  such  a  scheme 
have  argued  that  it  would  tend  to  pauperize  many 
parents  who  could  well  afford  to  provide  their 
children  with  good  and  sufficient  lunches.  What- 
ever may  be  the  arguments  pro  and  con  for  pro- 
viding pupils  of  public  schools  with  good  lunches, 
the  fact  remains  that  in  many  European  and  in 
some  American  communities  where  the  children 
have  been  provided  with  lunches  consisting  of 
meat  sandwiches  and  a  glass  of  milk — hot  in  winter 
and  cold  in  summer — they  have  all  increased  in 
weight,  have  done  better  work  at  school  than 
prior  to  the  inauguration  of  the  lunch  era,  and 
last  but  not  least,  have  all  been  made  more  happy. 
It  would  seem  to  me  that  the  objection  to  the  ab- 
solutely free  distribution  of  lunches  could  be  met 
by  providing  them  to  the  children  at  cost  price. 
If  the  parents  felt  that  they  could  not  afford  to 
pay  this  trifling  amount,  they  should  be  instructed 
to  make  application  to  the  proper  authorities  who 
would  investigate  the  case  and  see  to  it  that  meal 


264  TUBERCULOSIS 

tickets  were  given  gratuitously  to  these  children 
when  it  was  necessary.  Nearly  every  American 
city  and  town  has  its  Charity  Committee  whose 
important  function  it  is  to  investigate  reported 
cases  of  poverty  and  distress,  and  to  see  that 
pauperization  is  avoided.  By  reporting  to  such 
organizations  the  families  which  had  asked  for 
free  lunch  tickets  for  their  children,  injustice  and 
mistakes  would  be  avoided  and  cases  of  true  dis- 
tress discovered.  Not  to  make  the  child  feel  hu- 
miliated because  it  must  receive  free  lunches  on 
account  of  its  parents'  poverty,  all  children  should 
have  tickets;  those  who  are  able  should  pay  for 
them;  to  those  not  able  they  should  be  given  dis- 
creetly by  the  teacher  or  sent  to  the  parents  to  be 
handed  to  the  child. 

The  danger  of  occasionally  giving  a  free  lunch 
to  a  child  whose  parents  ought  to  pay  for  it 
should  not  deter  us  from  providing  the  hungry  chil- 
dren not  only  with  sufficient,  but  also  with  nutri- 
tious food.  Sometimes  the  children  are  given 
money  by  their  parents,  and  instead  of  buying 
substantial  lunches  they  spend  the  money  for 
candy  or  indigestible  pastry. 

All  pupils  and  students  in  public,  parochial,  and 
private  schools  and  colleges  should  be  instructed, 
according  to  their  age  and  understanding,  in  the 
principles  of  the  prevention  of  tuberculosis  and  in 


INSTRUCTION  FOR  CHILDREN  265 

hygiene  in  general.  While  for  older  pupils  much 
of  what  has  been  said  in  the  preceding  chapters 
may  be  readily  understood  and  digested,  for  smaller 
children  simplicity  and  directness  are  essential  if 
we  wish  to  make  the  pupil  remember. 

Following  is  an  alphabet  which  I  have  com- 
piled, believing  that  it  will  suit  the  understanding 
of  younger  pupils  in  public  or  private  schools. 
In  this  alphabet  I  have  endeavored  to  point  out 
the  numerous  sources  of  tuberculous  infection  to 
which  the  child  may  be  exposed  at  school,  and 
what  the  child  itself  can  do  to  overcome  the  possible 
sources  of  infection.  I  should  like  to  see  this 
alphabet,  or  some  similar  directions  and  rules, 
read  and  explained  by  the  teachers  in  public  and 
private  schools,  say  about  once  a  month,  and  copies 
of  them  distributed  to  the  children  to  take  home, 
to  be  read  by  the  parents  and  reread  by  themselves. 

Alphabet  in  the  Prevention  of  Tuberculosis. 
A    is  for  Anybody  who  can  help  prevent  consumption, 

a  child  just  as  well  as  a  grown  person. 
B    is  for  Breathing  which  you  should  learn  to  do  deeply; 

often  take  deep  breaths  in  fresh  air. 
C    is  for  Coughing  which  you  should  never  do  in  any 

one's  face,  nor  should  you  sneeze  in  any  one's  face. 

Turn  away  your  head  and  hold  your  hand  before 

your  mouth. 
D   is  for  Don't,    Don't  swap  apple  cores,  candy,  chew- 


266  TUBERCULOSIS 

ing  gum,  half-eaten  food,  whistles,  bean-blowers, 
or  anything  you  put  in  your  mouth. 

E  is  for  Eating  no  fruit  that  has  not  been  washed  or 
peeled,  or  anything  that  is  not  clean. 

F  is  for  Fingers  which  should  not  be  put  in  the  mouth 
nor  wet  to  turn  the  pages  of  books. 

G  is  for  Giving  a  good  example  to  your  fellow  pupils 
and  playmates  by  being  always  neat  and  clean, 
just  as  much  so  at  home  as  at  school. 

H  is  for  Handkerchief  which  should  be  used  only  to 
wipe  your  nose  and  not  your  slate,  desk,  or 
shoes. 

I  is  for  Illness  of  other  kinds  besides  consumption 
which  following  these  rules  will  help  prevent,  such 
as  colds,  measles,  grippe,  diphtheria,  and  pneu- 
monia. 

J  is  for  Joints  where  children  have  tuberculosis  more 
often  than  in  their  lungs. 

K  is  for  Keeping  your  finger-nails  clean.  A  scratch 
from  a  dirty  finger-nail  may  make  a  bad  sore. 

L  is  for  Learning  to  love  fresh  air,  and  not  for  learn- 
ing to  smoke. 

M  is  for  Mouth  which  is  meant  to  put  food  and  drink 
into,  and  not  meant  for  pins  and  money  or  any- 
thing not  good  to  eat. 

N  is  for  Nose  which  you  never  should  pick  nor  wipe 
on  your  hand  or  sleeve. 

O  is  for  Outdoors  where  you  should  stay  just  as  much 
as  you  can;  always  play  outdoors  unless  the 
weather  is  too  stormy. 


INSTRUCTION  FOR  CHILDREN  267 

P  is  for  Pencils  which  you  should  not  wet  in  your 
mouth  to  make  them  write  blacker. 

Q  is  for  Questions  which  you  should  ask  the  teacher  if 
you  don't  understand  all  these  rules. 

R  is  for  Roughness  in  play  by  which  you  may  hurt 
yourself  or  your  comrades.  If  you  have  cut  your- 
self, been  hurt  by  others,  or  feel  sick,  don't  fear  to 
tell  the  teacher. 

S  is  for  Spitting  which  should  never  be  done  except  in 
a  spittoon,  or  a  piece  of  cloth,  or  handkerchief  used 
for  that  purpose  alone.  Never  spit  on  a  slate,  on 
the  floor,  the  playground,  or  the  sidewalk. 

T  is  for  Teeth  which  you  should  clean  with  toothbrush 
and  water  after  each  meal,  or  when  you  get  up  in 
the  morning  and  before  you  go  to  bed  at  night. 

U  is  for  Unkind  which  you  should  never  be  to  a  con- 
sumptive. 

V  is  for  Vessel  like  drinking  cups  and  glasses  which 

should  not  be  used  by  one  child  after  another 
without  being  washed  in  clean  water  each  time. 

W  is  for  Washing  your  hands  with  soap  and  water  be- 
fore each  meal,  even  if  it  is  only  lunch. 

X  is  for  the  X-ray  which  sometimes  helps  to  discover 
consumption  or  other  forms  of  tuberculosis. 

Y  is  for  You  who  should  never  kiss  anybody  on  the 

mouth  nor  allow  them  to  do  so  to  you. 
Z    is  for  Zeal  in  carrying  out  these  rules. 

In  order  to  combat  tuberculosis  in  the  public 
schools,   the  teachers   should  receive  special   in- 


568  TUBERCULOSIS 

structions  so  that  they  may  recognize  the  outward 
symptoms  of  the  disease  in  childhood.  A  child 
which  grows  more  indifferent  to  its  studies,  be- 
comes irritable  or  morose,  tires  easily,  has  a  little 
fever  in  the  afternoon,  seems  to  lose  in  weight, 
looks  pale,  shows  swelling  of  glands,  even  if  it 
does  not  cough,  should  be  reported  at  once  to  the 
school  physician  for  examination,  as  such  condi- 
tions are  typical  and  often  precede  the  outbreak 
of  pulmonary  tuberculosis.  To  weigh  the  pupils 
periodically  and  keep  a  record  of  the  results  will 
often  be  helpful  in  discovering  a  beginning  of  the 
disease. 

The  early  symptoms  of  tuberculosis  of  the  bones 
and  joints  manifest  themselves  in  lameness  and 
easy  tiring  of  the  arm  or  leg  affected.  A  light 
pressure  in  the  region  of  the  joints  causes  a  sudden 
severe  pain.  If  the  spinal  column  is  affected,  the 
symptoms  will  depend  upon  the  location  of  the  ver- 
tebra which  is  attacked  by  the  disease.  For  ex- 
ample, if  this  should  be  in  the  region  of  the  neck, 
there  will  be  difficulty  in  swallowing,  in  breathing, 
or  a  frequent  dry  cough.  If  any  one  of  the  verte- 
brae in  the  region  of  the  chest  is  affected,  a  feeling 
of  constriction  like  a  tight  band  around  the  chest 
will  be  observed,  accompanied  often  ])y  digestive 
troubles.  If  the  seat  of  the  disease  is  in  the  lower 
portion  of  the  spinal  column,  there  will  be  irrita- 


SCROFULOUS  CHILDREN  269 

tion  of  the  bladder  and  lower  bowels,  an  inclina- 
tion to  much  urinating,  and  radiating  pains  toward 
the  hips. 

The  above  mentioned  pulmonary  type  of  tuber- 
culosis is  relatively  rare  in  children.  On  the  other 
hand,  among  the  little  ones  tuberculosis  manifests 
itself  very  often  not  only  as  the  bone  and  joint 
affections  just  described,  but  also  in  another  form 
known  as  scrofula  or  scrofulosis  and  which  might 
be  considered  almost  exclusively  a  disease  of  chil- 
dren. The  scrofulous  child  is  usually  pale,  with 
flabby  skin  and  muscles.  The  glands  around  the 
neck  are  swollen,  and  skin  disease,  sore  eyes,  and 
running  ears  are  frequent  symptoms.  The  little 
patient  usually  manifests  a  phlegmatic  condition, 
but  we  may  also  find  some  that  are  nervous  and 
irritable.  The  latter  often  have  a  particularly 
white,  delicate  skin  which  makes  the  veins  visible. 
Fever  is  usually  present  in  the  beginning  of  the  pul- 
monary type  of  tuberculosis;  it  must  be  borne  in 
mind  that  we  occasionally  find  a  high  temperature 
also  in  scrofulosis. 

All  children  on  entering  school  should  be  ex- 
amined for  tuberculosis  or,  at  least,  have  a  certifi- 
cate from  their  family  physician  showing  freedom 
from  this  disease. 

When  the  child  in  the  public  school  has  been 
discovered  to  be  tuberculous,  or  strongly  predis- 


270 


TUBERCULOSIS 


Fig.  69.     Open  Air  School  at  Providence,  R.   I. 


posed,  what  then?  For  those  shghtly  affected 
with  pulmonary  or  glandular  tuberculosis,  there 
should  be  provided  an  open  air  school,  such  as 
was  first  established  in  this  country  in  Providence, 
R.  I.  (Fig.  69),  and  later  in  New  York  and  other 
cities  of  the  United  States.  If  I  am  rightly  in- 
formed, the  first  one  established  in  England  was 
the  London  County  Council  open  air  school  at 
Horniman  Park,  Lordship  Lane,  of  which  I  give 
an  interesting  illustration.    (Fig.  70.) 

The  school  in  Providence,  R.  L,  was  the  out- 
growth of  the  work  of  the  local  Society  for  the 
Prevention  of  Tuberculosis  and  owes  its  incep- 
tion mainly  to  the  enthusiasm  of  Dr.  J.  Perkins, 


OPEN  AIR  SCHOOLS 


271 


Fig.  70.     London  City  Council  Open  Air  School  at  Horniman  Park — 

Resting  Time. 

a  member  of  that  association.  The  school  was 
opened  January  27,  1908.  It  is  situated  in  Meet- 
ing Street,  where  there  was  an  old  schoolhouse 
that  could  be  utilized  for  the  purpose.  The  accom- 
panying picture  will  show  that  a  part  of  the 
brick  wall  had  to  be  taken  out  in  order  to  make  it 
truly  an  open  air  school.  The  part  of  the  building 
thus  opened  was  fitted  with  large  window  sashes 
which  let  into  the  schoolroom  air  and  sunshine  in 
large  quantities.  The  physicians  interested  in  the 
plan  have  volunteered  their  services  for  visitation 
and  inspection  of  the  school,  and  also  interested 
themselves  in  the  necessary  food  supply.  The  regu- 
larly prescribed  studies  of  the  public  school  course 


272 


TUBERCULOSIS 


Fig.  71.      Open  Air  School  on  the  "  Southfield,"  a  Discarded  Ferry- 
boat Anchored  at  Foot  of  East  26th  Street,  New  York  City. 


are  taught,  and  teachers  peculiarly  fitted  for  the 
kind  of  work  required,  have  been  appointed. 

The  schoolroom  is  large  and  airy,  having  win- 
dows on  three  sides.  On  the  south  side  are  the 
five  large  windows  where  the  wall  was  removed, 
reaching  from  the  ceiling  nearly  to  the  floor,  so  ar- 
ranged with  hinges  and  pulleys  that  they  can  be 
swung  inward,  practically  opening  the  entire  side 
of  the  building.  These  windows  are  kept  open  in 
all  weathers  except  when  snow  or  rain  beat  in.  So 
far  they  have  never  l)een  closed. 

To  temper  the  air  at  one  end  of  the  room  are 


OPEN  AIR  SCHOOLS  273 

two  stoves,  one  for  heating  simply;  the  other,  a 
cook  stove,  for  warming  the  soapstones  and  the 
mid-forenoon  soup.  The  temperature  of  the  room 
in  winter  frequently  goes  below  40°  F. 

The  room  is  equipped  with  adjustable  desks  and 
chairs  on  platforms  so  that  they  may  be  moved  at 
will.  They  have  been  fitted  to  the  needs  of  each 
individual  child.  The  sun  enters  the  schoolroom 
at  9 130  and  remains  there  all  day,  and  the  desks  are 
so  moved  that  while  breathing  the  fresh  air  the 
pupils  also  get  the  benefit  of  a  sun  bath. 

The  pupils  are  supplied  with  large,  wadded 
bags  reaching  from  the  feet  to  the  waist,  and  for 
extreme  cold  weather  soapstones  are  provided. 
They  wear  outer  wraps  and  hats  or  not,  according 
to  their  needs.  At  10:15,  strong,  hot  soup  is  given 
them;  a  gallon  a  day  is  provided.  The  morning 
session  is  from  9  to  11:45,  ^^i^h  thirty  minutes  in- 
termission, and  the  afternoon  session  from  i  :45  to 

3-30- 
Another  interesting  experiment  in  the  line  of 

outdoor  schools  has  been  made  in  New  York  in 
connection  with  a  day  camp  for  the  consumptive 
poor  of  that  city.  Of  the  mission  of  the  day  camp 
we  will  speak  in  a  subsequent  chapter.  Here  it 
may  simply  be  stated  that  this  camp  owes  its  ex- 
istence to  the  enthusiasm  and  energy  of  Drs.  John 
W.  Brannan,  the  President  of  Bellevue  Hospital 


274  TUBERCULOSIS 

Board,  and  to  his  co-worker  Dr.  James  Alexander 
Miller.  It  is  located  on  the  old  discarded  ferry- 
boat, the  ''Southfield,"  which  is  anchored  at  the 
foot  of  East  26th  Street,  near  the  grounds  of 
Belle\Tie  Hospital.  The  ''Southfield"  open  air 
school  (Fig.  71)  admits  any  child  of  school  age. 
]\Iost  of  the  children  come  from  very  poor  homes, 
and  a  large  proportion  are  orphans.  All  those 
who  attend  the  class  are  either  tuberculous  or 
undoubtedly  predisposed  to  it. 

The  problem  of  teaching  the  tuberculous  child 
who  comes  from  the  districts  of  the  poor  and  who, 
by  reason  of  his  illness,  has  often  had  more  freedom 
than  is  good  for  him,  is  a  difficult  one.  The  chil- 
dren at  the  Southfield  school  have  to  learn  that  at- 
tendance at  school  is  not  at  their  own  whim  or 
pleasure;  that  school  means  work;  that  each  child 
must  not  only  come  every  day,  but  must  come 
early  enough  to  get  his  breakfast  and  begin  work 
at  9  o'clock. 

We  have  already  mentioned  phthisiophobia  in 
relation  to  adult  consumptives.  Some  people  carry 
their  fear  so  far  as  to  include  the  children.  I 
know  that  in  a  western  town  strong  objections 
were  made  recently  to  the  establishment  of  an 
open  air  school.  To  all  those  sharing  such  a  preju- 
dice, I  may  say  that  my  personal  experience  and 
that  of   the   teachers  of  schools   for  tuberculous 


OPEN  AIR  SCHOOLS  275 

children,  has  shown  that  children  as  a  rule  cough 
less  and  expectorate  less  than  adults;  that  when  in- 
structed to  be  careful  they  usually  are  so ;  and  that 
in  mental  equipment  and  deportment  the  tubercu- 
lous children  are,  as  a  rule,  on  a  par  with  any  un- 
exceptional class  of  children  from  average  homes. 
In  one  of  our  New  York  open  air  schools,  with 
which  I  am  familiar,  the  children  come  from  more 
destitute  and  worse  regulated  homes  than  the  av- 
erage, yet  these  little  ones  have  become  just  as  am- 
bitious to  work  and  just  as  well  behaved  as  any 
others. 

There  must  come  a  time,  and  soon,  when  we 
will  have  to  have  a  good  many  more  open  air 
schools,  not  only  for  the  predisposed  and  actually 
tuberculous  children,  but  also  for  the  seemingly 
normal,  healthy  child.  It  is  well  known  to  all 
pathologists  and  to  physicians  with  large  ex- 
perience in  the  treatment  of  diseases  of  children, 
that  many  a  child  has  a  latent  tuberculosis  which 
does  not  show  nor  develop  until  the  age  of  man- 
hood or  womanhood.  Thus,  it  would  seem  to 
me  that  to  increase  the  resisting  power  of  the 
child  during  the  school  age  (8  to  14),  we  should 
give  it  an  abundance  of  fresh  air.  In  some  sec- 
tions of  our  country,  such  as  southern  California 
and  some  of  the  southern  states,  I  should  think 
the  climate  would  permit  open  air  schools  pretty 


276  TUBERCULOSIS 

nearly  all  the  year  around.  In  some  other  sec- 
tions they  could  be  held  at  least  part  of  the  spring, 
summer,  and  fall,  provided  the  children  are  prop- 
erly clad. 

A  child  afflicted  with  more  advanced  pulmonary 
tuberculosis  should  not  even  go  to  the  public  open 
air  school  of  the  city.  It  should  be  sent  to  a  sana- 
torium. The  same  must  be  said  of  children  af- 
flicted with  bone  and  joint  tuberculosis.  For  both 
classes  of  children  the  sanatorium  treatment  is 
essential.  Surgical  cases  at  times  need  to  be  op- 
erated upon. 

We  reproduce  here  a  picture  of  the  first  san- 
atorium established  for  tuberculous  children  in 
France,  known  as  I'Hopital  pour  les  Enfants  Tu- 
berculeux  a  Berck-sur-Mcr.  (Fig.  72.)  It  is  main- 
tained by  the  municipality  of  Paris,  and  attached 
to  it  is  a  public  school.  Children  suffering  with  the 
surgical  type  of  tuberculosis  are  here  treated  and 
cared  for.  Those  able  to  pay  are  charged  a  mod- 
erate price  and  the  poor  are  treated  gratuitously. 
We  also  reproduce  the  playground  in  midwinter  of 
our  first  American  Sanatorium  for  children  suffer- 
ing with  tuberculous  bone  diseases,  at  Sea  Breeze, 
Coney  Island.    (Fig.  73.) 

It  goes  without  saying  that  no  sanatorium  for 
children  should  exist  without  proper  educational 
facilities  so  that  the  intellectual  development  of  the 


3 


u 


D 

h 


278 


TUBERCULOSIS 


Fig.  73.      Playground  in   Midwinter  for  Tuberculous  Children 
at  Sea  Breeze,  Coney  Island,  New  York. 

child  may  go  hand  in  hand  with  its  physical  im- 
provement. 

In  Boston  this  work  is  under  the  direction  of 
Dr.  Edwin  A.  Locke,  and  while  teacher  and 
physician  work  in  perfect  harmony,  the  latter  is 
the  supreme  authority  in  the  mental  as  well  as 
the  physical  care  of  the  children. 

A  tuberculous  teacher,  that  is  to  say,  one  suffer- 
ing with  an  open  and  active  pulmonary  tubercu- 


ANTI-TUBERCULOSIS    EDUCATION        279 

losis,  coughing  and  expectorating,  should  not,  for 
his  own  sake  as  well  as  that  of  the  pupils,  be  per- 
mitted to  teach  in  public  schools.  He  should 
be  given  opportunity  to  be  cured  of  his  disease 
either  in  a  sanatorium,  a  health  resort,  or  at 
home. 

If  his  tuberculous  trouble  has  been  arrested  or 
cured,  in  order  to  have  the  cure  made  more  per- 
manent or  to  prevent  a  relapse,  he  should  be 
employed  as  a  teacher  in  one  of  the  open  air 
schools  or  in  the  school  attached  to  a  children's 
sanatorium. 

Since  tuberculosis  is  very  justly  considered  a 
disease  of  the  masses,  the  teaching  of  hygiene  and 
prophylaxis  of  tuberculosis  should  be  made  a  part 
of  the  curriculum  in  high  schools,  colleges,  semi- 
naries, and  universities  where  teachers  and  edu- 
cators receive  their  training. 

Evening  lectures  on  hygiene  and  tuberculosis, 
given  for  the  adults  in  the  public  school  buildings, 
such  as  were  inaugurated  some  years  ago  by 
Dr.  Henry  M.  Leipziger  of  the  New  York  Board 
of  Education,  have  proved  a  most  valuable  feature 
in  educating  the  public  on  this  vital  subject. 
From  personal  experience  I  know  that  intense  in- 
terest has  been  manifested  by  the  public  in  such 
lectures. 

One  of  the  best  educators  of  the  masses,  how- 


28o  TUBERCULOSIS 

ever,  is  the  public  press.  Short  articles  on  the 
various  phases  of  the  tuberculosis  problem  writ- 
ten by  competent  physicians  in  the  language  of 
the  people,  should  appear  frequently  in  every 
daily  newspaper.  A  vast  amount  of  education 
can  thus  be  effected  and  people  who  can  not  be 
reached  by  any  other  means  will  be  made  famil- 
iar with  the  principal  points  in  the  prevention  of 
tuberculosis. 

There  is  also  another  way  in  which  the  public 
press,  more  than  any  other  agent,  can  serve  the 
public  weal  and  the  anti-tuberculosis  cause  at 
the  same  time.  That  is  by  refusing  to  publish 
any  patent  medicine  advertisements,  secret  rem- 
edies, methods  which  promise  sure  consumption 
cures,  or  anything  that  may  in  any  other  way 
mislead  the  public  and  prevent  them  from  seeking 
proper  medical  advice  and  scientific  treatment 
while  there  is  still  a  chance  for  improvement  and 
cure. 

School  authorities  or  other  educational  bodies 
should  consider  the  education  of  the  future  mothers 
of  the  nation  an  important  factor  not  only  in  tu- 
berculosis, but  also  in  all  other  diseases.  There 
should  be  no  girls'  schools  where  cooking  and 
housekeeping  do  not  form  a  part  of  the  curric- 
ulum. The  duties  of  the  future  mother  or  house- 
wife should  be  taught  to  our  girls,  and  the  now  ex- 


ANTI-TUBERCULOSIS  EDUCATION        281 

isting  uneducated  mothers  and  housewives  should 
be  taught  what  they  do  not  know.  The  rearing  of 
healthy  children  is  the  most  valuable  asset  to  a 
nation's  strength  and  prosperity. 

An  institution  known  as  "Caroline  Rest"  was 
recently  established  in  Hartsdale,  Westchester 
County,  N.  Y.,  by  Mr.  Geo.  H.  F.  Schrader,  in 
memory  of  his  mother,  and  presented  to  the  New 
York  Association  for  Improving  the  Condition  of 
the  Poor.  This  institution  is  not  only  a  sanatorium 
for  mothers  with  infants,  but  serves  above  all  as 
a  school  where,  under  the  most  favorable  condi- 
tions, mothers  of  the  poor  will  receive  instruc- 
tion in  the  duties  of  motherhood,  in  personal  hy- 
giene, the  care  of  their  children,  and  the  right 
conduct  of  their  homes.  It  was  planned  to  meet 
the  pathetic  needs  of  that  great  number  of  poor 
mothers  who  are  compelled  to  leave  their  beds 
within  a  week  after  childbirth,  in  order  to  re- 
turn to  the  factory  or  to  the  care  of  the  house- 
hold, thus  laying  the  foundation  of  a  lifelong 
invahdism. 

The  work  at  Hartsdale  is  supplemented  in  the 
city  by  the  Caroline  Rest  nurses  who  visit  mothers 
before  and  after  confinement,  and  through  in- 
struction and  special  care  promote  their  health 
and  that  of  their  children.  The  experience  of  the 
Caroline  Rest  nurses  has  definitely  shown  that  by 


282  TUBERCULOSIS 

protecting  the  health  of  mothers  before  the  com- 
ing of  the  new  hfe,  it  is  possible  greatly  to  reduce 
the  mortality  among  infants  under  one  year  of 
age,  of  whom  approximately  17,000  now  die  in 
Greater  New  York  every  year  from  causes  largely 
preventable.  A\niat  such  care  of  mothers  and  such 
prenatal  and  postnatal  care  of  children  means 
in  the  prevention  of  tuberculosis  must  be  evident. 

There  exist  already  in  a  few  cities  in  the  United 
States  what  are  known  as  practical  housekeeping 
centers.  The  first  of  these  was  established  in 
1 90 1  by  ]\Iiss  LiUian  D.  Wald,  head  of  the  Henry 
Street  Nurses'  Settlement  of  New  York  City. 
Such  a  center  is  an  institution  in  the  shape  of  a 
model  flat  or  model  house,  and  teaches  the  in- 
experienced mother  or  girl,  by  precept  and  ex- 
ample, how  to  cook,  how  to  train  children,  and 
how  to  keep  even  the  modest  home  neat,  clean, 
and  attractive.  These  centers  meet  the  need  of 
the  inexperienced  mother  of  to-day,  of  to-morrow, 
and  of  the  mother  ten  years  hence. 

To  show  the  value  of  such  educational  and 
practical  housekeeping  centers,  I  can  not  do  better 
than  quote  from  the  writings  of  that  well-known 
teacher  of  mothers  and  girls,  and  philanthropic 
worker,  Mrs.  Florence  Kelly.  Here  is  what  she 
has  to  say: 

''If  the  practical  housekeeping  centers  can  be 


ANTI-TUBERCULOSIS  EDUCATION        2^3 

made  permanent  and  numerous  enough,  if  they 
can  be  made  as  much  a  part  of  the  hfe  of  the  com- 
munity as  the  pubhc  schools  are  now,  intergraded 
in  time  with  the  schools,  these  problems — intem- 
perance, infant  mortality,  and  reduced  vitality  of 
the  working  class  families — can  be  reduced  to  their 
lowest  terms.  Clean,  orderly  homes,  in  which  air 
is  pure,  food  is  attractive  and  wholesome,  and  beds 
are  clean  and  comfortable,  give  the  baby  the 
maximum  chance  for  life  and  health,  and  his 
father  an  opportunity  for  keeping  himself  fit  for 
his  work,  and  a  hope  of  escaping  his  deadliest 
enemy — drink  and  tuberculosis." 

Finally,  educators  of  all  kinds  should  not  fail 
to  impress  upon  the  minds  of  those  with  whom 
they  come  in  contact  that  whatever  is  done  for 
the  anti-tuberculosis  crusade  is  for  the  good  of 
the  whole  community.  Many  parents  have  been 
antagonistic  to  the  medical  inspection  of  school 
children,  nevertheless  this,  and  the  special  ex- 
amination for  tuberculosis  so  thoroughly  carried 
out  in  New  York  under  the  direction  of  Dr.  Wal- 
ter Bensel,  the  Sanitary  Superintendent,  Drs. 
John  J.  Cronin  and  Josephine  Baker  of  the  De- 
partment of  Child  Hygiene,  and  Dr.  Bertram  H. 
Waters,  Chief  of  IMunicipal  Clinics,  have  been  of 
incalculable  service  in  the  early  recognition  of  tu- 
berculosis and  have  saved  many  a  young  life. 


CHAPTER  X 

THE  DUTY  OF  THE  CLERGY,  PHILANTHROPISTS, 
CBL4RITABLE  INDIVIDUALS,  AND  CHARITY  OR- 
GANIZATIONS 

The  clergyman  has  as  great  a  mission  to  perform 
in  the  prevention  of  tuberculosis  as  a  disease  of 
the  masses  as  anybody  else.  Every  clergyman 
should  inculcate  ideas  on  general  sanitation,  the 
value  of  good,  pure  air  and  proper  living  into  the 
minds  of  the  people  under  his  charge.  He  and 
they  should  feel  a  pride  in  having  their  churches 
and  Sunday  schools  hygienically  constructed  and 
well  ventilated.  To  close  the  church  doors  and  all 
the  windows  immediately  after  divine  service  on 
Sunday,  is  an  unpardonable  hygienic  sin  which  no 
clergyman  ought  to  allow.  A  church  should  be 
aired  before  being  closed  for  the  week  and  again 
before  service  is  held.  The  air  in  a  church  or  Sun- 
day school  should  be  as  good  as  anywhere,  if  not 
better.  Fixed  carpets  should  not  be  used  in  places 
of  worship  where  many  people  congregate.  Kiss- 
ing the  bible  when  taking  an  oath  should  be  dis- 
couraged ])y  jurists  and  divines.     Bacteriological 

284 


CHURCH  HYGIENE  285 

examinations  of  bible  covers  used  for  that  purpose 
have  more  than  once  shown  the  danger  of  such  a 
practice.  The  bacilli  of  tuberculosis  have  often 
been  found  on  these  covers  in  great  numbers. 

In  Roman  and  Greek  Catholic  churches  all  ar- 
ticles of  adoration  such  as  crosses,  statues,  and 
pictures,  which  are  often  kissed  by  devout  Catho- 
lics, should  be  disinfected  frequently.  I  am  pleased 
to  note  that  there  are  some  very  progressive  priests 
in  the  Roman  Catholic  church  who  are  fully  aware 
of  the  danger  which  may  come  from  such  practices 
and  who  insist  upon  a  thorough  cleansing  of  these 
articles.  The  Bishop  of  Fano  in  Italy  even  goes 
a  little  further.  In  a  circular  issued  by  him,  he 
asks  the  priests  of  his  diocese  to  comply  with  the 
following  rules: 

1.  In  every  church  the  floor  must  be  regularly  cleaned 
with  sawdust,  saturated  with  a  strong  sublimate  solu- 
tion. This  thorough  cleaning  should  take  place  par- 
ticularly after  holidays  when  great  masses  of  people 
have  visited  the  church. 

2.  Every  week  all  ordinary  chairs  and  confessional 
chairs  must  be  thoroughly  cleaned  with  moist  rags. 

3.  The  grate  of  the  confessional  chairs  must  be 
washed  every  week  with  lye  and  then  polished. 

The  ritual  circumcision  practiced  according  to 
the  orthodox  Jewish  rite  may,  if  the  operator  hap- 


286  TUBERCULOSIS 

pens  to  be  consumptive,  be  the  cause  of  the  in- 
fant contracting  tuberculosis.  The  operation  of 
circumcision,  when  skillfully  and  rapidly  per- 
formed, is  in  itself  trifling;  but  the  application  of 
the  operator's  lips  afterwards  for  the  purpose  of 
stopping  the  bleeding  makes  it  dangerous. 

Since  it  will  be  difficult  to  stop  this  practice  by 
a  simple  protest  on  the  part  of  physicians,  and  as 
the  law  can  not  interfere  with  the  free  exercise  of 
a  religious  rite,  I  should  suggest  as  a  remedy  that 
only  such  persons  should  be  allowed  to  perform 
circumcision  as  have  shown  the  necessary  skill 
before  a  medical  board  of  examiners,  and  that 
every  time  they  are  called  to  perform  the  rite  they 
should  submit  themselves  to  a  medical  examina- 
tion. Only  when  bearing  a  certificate  from  a 
regular  physician,  stating  the  absolute  freedom 
from  specific  diseases,  should  they  be  allowed  to 
perform  ritual  circumcision.  As  another  reliable 
measure  against  the  possibility  of  inoculating  the 
child,  when  the  parents  insist  upon  the  orthodox 
method  of  circumcision,  is  the  suction  by  the  aid 
of  a  glass  tube,  as  practiced  in  France  and  Ger- 
many. 

The  common  communion  cup  in  Protestant 
churches  should  be  replaced  by  individual  com- 
munion cups.  This  practice,  while  accepted  by 
many  liberal  churches,  is  not  looked  upon  with 


CHURCH  HYGIENE  287 

favor  by  those  confessing  the  more  orthodox  creeds. 
For  these  a  cup  has  been  devised  which  has  the 
advantage  over  the  ordinary  cup  that  the  secretions 
of  any  one  mouth  do  not  come  in  contact  with  an- 
other. The  device  consists  of  an  ordinary  chahce 
about  five  inches  across  the  opening,  with  an  attach- 
ment of  metal  which  each  communicant  may  have 
and  place  upon  the  rim  of  the  chalice.  If  any  of 
the  fluid  remains  after  the  communicant  has  im- 
bibed, it  flows  into  a  false  cup  and  into  a  reservoir 
at  the  bottom  of  the  chalice.  The  supply  cup  is 
separate  in  the  center  of  the  chalice,  and  is  so  ar- 
ranged that  it  automatically  fills  every  time  that  it 
is  used,  the  amount  being  regulated  at  will.  When 
they  do  not  have  the  individual  metallic  mouth 
clips  to  attach  to  the  rim  of  the  chalice,  a  number 
of  layers  of  thin  waxed  paper,  cut  and  formed  to 
fit  tightly  as  a  pad,  are  attached  to  the  rim.  After 
the  communicant  has  used  the  cup,  by  a  sweep  of 
the  thumb  and  forefinger  the  individual  wax 
paper  which  has  been  used  is  removed  from  the 
pad  and  a  clean  one  is  revealed.  (Fig.  74.)  This 
device  is  the  invention  of  a  Swedish  clergyman. 
Rev.  C.  J.  Ljunggren,  of  Providence,  R.  I.,  whose 
need  for  a  device  of  this  kind  led  him  to  invent 
this  ingenious  substitute  for  the  ordinary  cup. 

While  one  now  less  frequently  sees  patent  medi- 
cines and  sure  consumption  cures  recommended 


288 


TUBERCULOSIS 


or  endorsed  by  thoughtless  ministers,  such  rec- 
ommendations still  appear  now  and  then  in  the 

public  press.  It  is  self-evi- 
dent that  no  minister,  true 
to  his  calling,  should  ever 
do  this,  nor  should  religious 
newspapers  lend  their  col- 
umns to  advertise  remedies, 
the  action  of  which  on  the 
invalid  is  harmful  ninety- 
nine  times  out  of  a  hundred 
Fig.  74.    Rev.  Ljung-    g^^d   is   perhaps  never   help- 

gren's  Hygienic  Chalice.       -    , 

ful. 
Besides  practicing  the  preventive  measures 
just  enumerated,  the  ministers  of  the  various 
creeds  can  be  helpful  by  cooperating  with  physi- 
cians in  the  anti-tuberculosis  crusade.  Thus  very 
recently,  interesting  pamphlets  on  the  prevention 
of  tuberculosis  were  written  by  the  Rt.  Rev.  James 
A.  McFaul,  Bishop  of  Trenton,  and  the  Rev. 
Dr.  Joseph  Krauskopf,  a  distinguished  rabbi  of 
Philadelphia.  In  Rochester,  N.  Y.,  the  Rev.  Paul 
Moore  Strayer  honors  the  medical  profession  by 
inviting  physicians,  now  and  then,  to  occupy  the 
pulpit  on  Sundays  to  preach  on  health  topics,  and 
particularly  on  tuberculosis.  My  friend,  the 
Rev.  John  Haynes  Holmes,  honored  me  recently 
by  an  invitation  to  speak  on  tuberculosis  on  two 


CHURCH  HYGIENE  289 

successive  Sundays  before  the  Good  Citizenship 
Class  of  the  Unitarian  Church  of  the  Messiah  of 
New  York. 

Nearly  all  leading  denominations  in  the  United 
States  have  now  either  sanatoria  or  hospitals  for 
the  care  of  tuberculous  patients.  It  is  interesting 
to  note  that  the  Philadelphia  Protestant  Episcopal 
City  Mission  opened  a  hospital  for  consumptives 
as  early  as  1877.  This  institution  has  grown  to 
be  one  of  the  most  important  in  the  United  States. 
As  will  be  seen  from  the  accompanying  picture 
(Fig.  75),  it  now  occupies  a  large  tract  of  land 
with  numerous  buildings  and  cottages,  on  Chest- 
nut Hill,  Philadelphia. 

Under  the  auspices  of  the  Roman  Catholic 
Church  there  are  numerous  sanatoria  throughout 
the  United  States,  and  in  New  York  City  this 
church  renders  particular  service  to  the  tuber- 
culosis cause  by  admitting  to  the  St.  Joseph  and 
the  Seton  Hospitals  (Figs.  76  and  77)  not  only 
early  but  also  advanced  cases,  thus  removing 
centers  of  infection  from  many  homes. 

The  National  Jewish  Hospital,  which  was 
founded  by  the  Jewish  people  as  a  contribution 
to  the  world's  battle  against  the  white  plague,  is 
entirely  free  and  for  destitute  consumptives  only — 
no  paying  patients  are  received.  It  was  started 
some  ten  years  ago,  and  is  accomplishing  a  great 


ANTI-TUBERCULOSIS  SERMONS 


291 


r^:^ 


Fig.  76.     St.  Joseph  Hospital  for  Consumptives  in  All  Stages  of  the 
Disease,  New  York  City. 


deal  of  good  by  curing  many  cases  and  reestab- 
lishing the  earning  capacity  of  pulmonary  in- 
valids. This  institution  receives  incipient  cases 
only.    (Figs.  78  and  79.) 

What  is  most  interesting  and  gratifying  from  a 
humanitarian  point  of  view  is  that,  while  all  these 
institutions  are  nominally  under  Protestant,  Ro- 
man Catholic,  or  Jewish  direction,  all  of  them  are 
non-sectarian  in  their  work,  and  patients  of  all 
creeds  and  color  are  received  and  cared  for.  It 
must  not  be  forgotten,  however,  that  all  these 
hospitals  are  taking  care  of  the  consumptive  poor, 


292 


TUBERCULOSIS 


Fig.  77.    Nazareth  Branch  of  Seton  Hospital  for  Consumptive  Women 
and  Children,  in  Charge  of  the  Roman  Catholic  Sisters  of  Charity. 

and  in  order  that  their  good  work  shall  continue 
and  enlarge  they  must  receive  the  generous  finan- 
cial support  of  all  those  able  to  help  their  suffer- 
ing fellow-men. 

There  is  one  more  field  in  which  the  clergyman 
who  is  in  sympathy  with  physicians  and  who 
earnestly  desires  to  diminish  diseases  of  all  kinds, 
and  at  the  same  time  diminish  social  misery,  can 
be  helpful.  Both  disease  and  social  misery  are 
oftentimes  increased  by  custom  and  tradition,  and 
the  method  of  burial  of  the  dead  has  no  little  to  do 
with  the  welfare  of  the  living.  Medical  history  is 
full  of  incidents  showing  that  contagious  and  in- 
fectious diseases  have  been  propagated  from  su- 
perficially buried  bodies  which  had  succumbed  to 


DENOMINATIONAL  HOSPITALS 


■9^ 


Fig.  78.     The  National  Jewish  Hospital  for  Consumptives  at  Denver, 
Colo.     Men's  Pavilion.     Only  Incipent  Cases  Are  Admitted. 


infectious  diseases.  This  may  happen  through  a 
washing  away  of  the  soil  of  cemeteries,  through 
disinterment  of  the  individual  graves,  or  the  re- 
moval of  the  burial  ofround.  JNIen  and  beasts  alike 
have  been  known  to  become  diseased  and  die 
from  such  causes. 

But  it  would  seem  that  neither  floods  nor  dis- 
interments are  necessary  in  order  that  the  patho- 
genic microorganisms  may  work  their  way  to  the 
surface  and  then  be  the  cause  of  dangerous  in- 
fectious diseases.  Pasteur's  experiments  in  regard 
to  splenic  fever  of  cattle  (charbon)  are  suflicient 
evidence  of  this.    It  would  seem  that  the  burying 


■ 

1 

' 

-J 

-    J 

1 

^m 

Mtosll 

^^xrw 

^^^^^^^K. 

^^:-p^ 

1  '       i  ' 

ill  iiii  iliii 

2 

^S^iifei»>«4^ 

P^ 

■•B-            ^p^^WI 

^  lnrssE^a 

^vl^l 

1 

Fig.  79.     The  National  Jewish  Hosfjital  for  Consumptives  at  Denver, 
Colo.     The  Balconies  of  the  Circular  Pavilion  for  Women. 


CREMATION  295 

of  any  body  when  the  cause  of  death  was  an  in- 
fectious disease,  such  as  cholera,  yellow  fever, 
typhoid  fever,  diphtheria,  tuberculosis,  etc.,  may 
endanger  the  Hving.  According  to  Pasteur  and  the 
more  recent  experiments  of  Lortet  and  Despeignes, 
the  seemingly  innocent  earthworm  plays  a  very 
important  part  as  an  intermediary  in  bringing  to 
the  surface  living  pathogenic  (disease-producing) 
microorganisms.  The  observations  of  Lortet  and 
Despeignes  refer  particularly  to  Koch's  bacillus  of 
tuberculosis.  These  microorganisms  are  capable 
of  being  ingested  and  ejected  by  the  earthworm 
without  losing  their  virulence.  The  worms  swal- 
low earthy  matters,  and  after  separating  the  di- 
gestible and  serviceable  portion  they  reject  the 
remainder  in  little  coils  or  heaps  at  the  mouths  of 
their  burrows.  In  dry  weather  the  worm  descends 
to  a  considerable  depth  and  brings  up  to  the  surface 
particles  which  it  ejects.  It  would  thus  seem  that 
even  the  deeper  burial  of  the  bodies  is  no  guarantee 
that  living  infectious  microorganisms  will  not  be 
brought  to  the  surface. 

Cremation  has  often  been  advocated,  by  any 
number  of  physicians  and  sanitarians,  in  all  cases 
of  death  from  infectious  diseases,  l)ut  it  is  only 
since  the  experiments  of  Lortet,  Galtier,  Gartner, 
and  Schottelius  that  tuberculosis  has  been  included 
among  them,     These  experiments  have  demon- 


296  TUBERCULOSIS 

strated  conclusively  that  the  tubercle  bacillus  can 
resist  putrefaction  for  years  and  be  brought  to  the 
surface  by  the  earthworm. 

But  it  is  not  only  because  it  is  a  sanitary  measure 
that  I  plead  for  cremation.  I  claim  that  this  sim- 
pler and  more  expedient  way  of  disposing  of  the 
dead  would  be  an  economic  advantage  to  many  in- 
dividuals and  to  every  community  at  large. 

In  an  address  to  the  Chicago  Medical  Society, 
advocating  cremation,  Dr.  Charles  W.  Purdy  made 
some  striking  comparisons  to  show  what  a  burden 
is  laid  on  society  by  the  burial  of  the  dead.  Accord- 
ing to  his  carefully  prepared  estimate,  one  and  one- 
fourth  times  more  money  is  expended  annually  in 
funerals  in  the  United  States  than  the  government 
expends  for  public  school  purposes.  Hundreds  of 
acres  of  land  are  annually  consecrated  to  the  burial 
of  our  dead.  In  many  instances,  and  particularly 
in  the  vicinities  of  large  cities,  burial  lots  are  at  a 
premium.  In  some  of  our  fashionable  cemeteries 
in  New  York  one  can  not  buy  the  few  feet  of  ground 
needed  for  the  slow,  loathsome  decomposition  of 
his  body  for  less  than  Si, 000;  while  cremation, 
which  means  a  rapid  and  sanitary  decomposition, 
need  not  cost  more  than  $25.00. 

In  my  work  in  tuberculosis  I  have  been  led  to 
become  an  ardent  advocate  of  cremation,  especially 
in  our  large  communities,  and  particularly  for  peo- 


CREMATION  297 

pie  of  moderate  means  or  the  really  poor.  Perhaps 
the  danger  of  propagation  of  tuberculosis  through 
the  graveyard,  as  compared  with  other  diseases,  is 
relatively  small;  but  the  thousands  of  acres  which, 
near  large  cities,  are  devoted  to  the  dead  and  are 
thus  useless,  we  need  for  the  living. 

According  to  statistics  kindly  furnished  me  by 
Dr.  W.  H.  Guilfoy,  Registrar  of  Records  of  the 
City  of  New  York,  there  are  200  funerals  a  day, 
which  means  73,000  a  year,  out  of  which  only  the 
small  number  of  1,000  are  cremated.  Many  a 
model  tenement  house,  where  people  might  get 
light  and  air,  could  be  built  if  the  dozen  or  more 
graveyards  of  many  of  our  large  cities  were  laid  out 
in  building  lots  surrounded  by  little  parks  and 
playgrounds.  There  the  living  children  could  play 
and  the  living  mothers  and  wives  of  our  laboring 
men  could  get  a  breath  of  air,  which  it  is  so  difficult 
to  get  in  the  present  crowded  conditions  of  the 
average  tenement  districts.  Would  not  this  mean 
prevention  of  tuberculosis  and  other  diseases  due 
to  overcrowding,  among  old  and  young  alike  ? 

In  my  labors  among  the  consumptive  poor  I 
have  always  been  painfully  impressed  by  the  ex- 
pense which  the  ordinary  funeral,  including  the 
buying  of  a  burying  lot,  entails.  Consumption  is 
a  costly  disease.  If  the  patient  does  not  get  well 
within  a  year,  if  the  disease  becomes  chronic  and 


298  TUBERCULOSIS 

incurable  there  is  invalidism  and  loss  of  earning  ca- 
pacity often  for  two,  three,  and  more  years.  When 
the  end  comes,  there  is  no  end  to  the  expense.  A 
costly  coffin,  expensive  ceremonies,  and  a  costly 
burial  lot  sap,  in  many  cases,  every  resource  of  the 
relatives.  I  have  known  poor  people  to  go  into 
debt  for  the  sake  of  a  decent  funeral,  for  which 
it  took  years  to  pay.  In  view  of  such  experience, 
which  all  physicians  practicing  among  the  poor 
must  have  had,  are  we  not  justified,  is  it  not  our 
duty,  to  plead  for  the  relatively  inexpensive  dis- 
position of  the  dead  by  cremation,  and  for  simple 
funerals  ? 

I  am  fully  aware  that  there  are  valid  objections, 
first  on  medico-legal  grounds,  and  second  on  re- 
ligious grounds  to  which  a  plea  for  cremation  must 
give  due  consideration.  The  medico-legal  objec- 
tions could  be  met  with  by  permitting  no  cremation 
of  any  person,  the  causes  of  whose  death  was  not 
perfectly  known,  without  a  thorough  post-mortem 
inspection  of  the  entire  body  and  chemical  ex- 
amination of  the  stomach  and  intestines.  I  would 
suggest  a  law  that  a  complete  report  of  the  post- 
mortem findings  be  handed  to  the  proper  officials 
before  a  certificate  for  cremation  is  granted. 

To  the  objection  of  cremation  on  religious 
grounds,  it  is  not  my  province  to  reply.  Religious 
and  ethical  sentiments  must  be  honored  and  re- 


EMMANUEL  CHURCH  MOVEMENT         299 

spected,  but  I  am  quite  sure  that  the  clergy  of  any 
denomination,  even  those  opposing  cremation,  will 
agree  with  my  plea  for  more  simple  and  less  costly 
funerals  which,  in  the  families  of  the  consumptive 
poor,  are  so  often  productive  of  great  hardship. 

In  a  modern  book  on  tuberculosis,  a  chapter 
on  the  duties  of  the  clergy  in  this  great  problem 
can  not  be  considered  up  to  date  without  taking 
cognizance  of  the  anti-tuberculosis  work  of  what 
is  now  known  as  the  Emmanuel  Church  movement. 
While  this  work  in  its  relation  to  tuberculosis  has 
already  found  numerous  imitators,  it  originated 
with  Dr.  Joseph  H.  Pratt  and  the  Rev.  Dr.  Elwood 
Worcester  of  Boston.  It  was  the  thorough  scien- 
tific training  of  the  physician,  the  broad  humanity 
of  the  clergyman,  and  the  cooperation  of  sympa- 
thetic, devoted,  and  philanthropic  friends  which 
made  it  possible  to  obtain  most  surprising  results 
in  the  treatment  of  cases  in  all  stages  of  the  disease 
at  their  homes.  To  stimulate  similar  work  where 
it  is  not  yet  sufficiently  understood,  I  will  explain 
the  methods  whereby  Dr.  Pratt  and  his  co-workers 
obtained  such  unusually  good  results.  Of  twenty- 
eight  patients  in  all  stages  of  the  disease  no  less 
than  eighty  per  cent  were  reported  cured. 

These  patients  were  treated  according  to  their 
condition,  some  as  long  as  two  years,  in  "groups" 
in  or  near  their  homes,  after  the  most  approved 


3oo  TUBERCULOSIS 

hygienic  and  dietetic  methods  with  rest  in  the 
open  air,  and  constant  supervision  by  nurses  or 
friendly  visitors,  under  the  direction  of  an  ex- 
perienced phthisiotherapeutist.  Dr.  Pratt  has 
given  this  method  of  treating  a  number  of  pa- 
tients in  their  homes  the  name  ''class  method." 
He  emphasizes  that  in  order  for  it  to  be  successful 
the  classes  should  be  small  and  the  doctor,  the 
friendly  visitors,  the  nurses,  and  the  patients  should 
establish  close  relations  with  each  other.  It  is 
generally  understood  that  when  there  are  more 
than  twenty-five  patients,  a  second  class  should  be 
established. 

From  Dr.  Pratt's  own  writings  on  this  subject 
I  quote  the  following: 

''The  record  book  is  an  essential  part  of  the  class 
method.  The  patient  records  his  temperature,  his 
pulse-rate,  the  food  he  eats,  and  every  other  detail  of  the 
daily  life.  He  is  required  to  enter  in  this  diary  the  num- 
her  of  hours  he  is  out-of-doors  and  the  amount  of  milk 
he  drinks.  The  book  is  inspected  by  the  friendly  visitor 
at  every  visit  and  by  the  physician  at  the  weekly  meet- 
ing. In  my  expjerience  I  have  never  found  that  keeping 
the  records  leads  to  introspection  or  depression  of  spirits. 
It  is  a  great  aid  in  carrying  out  the  details  of  treatment. 
The  members  take  pride  in  keeping  neat  records.  It 
encourages  the  members  to  persevere. 

"The  weekly  meeting  is  the  distinct  feature  of  the 


CO-OPERATION  301 

class  system.  It  is  held  in  a  large  cheerful  room  at  the 
Massachusetts  General  Hospital.  The  class  meeting  is 
a  pleasant  social  hour  for  the  members.  One  confided 
to  the  friendly  visitor  that  the  meeting  was  her  weekly 
picnic.  ]\Iade  up  as  our  membership  is  of  widely  differ- 
ent races  and  different  sects,  thev  have  a  common  bond 
in  a  common  disease.  A  fine  spirit  of  camaraderie  has 
been  developed.  They  never  discuss  their  symptoms, 
and  are  almost  invariably  in  good  spirits.  Frequently 
our  graduates  (cured  patients)  drop  in  at  the  meeting  to 
get  weighed  and  to  greet  their  old  associates.  The  mem- 
bers are  weighed  each  week  and  their  pulse  and  tem- 
perature taken  by  the  friendly  visitors,  assisted  by  one 
of  the  senior  members.  The  greatest  gains  in  weight 
are  posted  conspicuously  each  wT€k  on  the  blackboard, 
and  the  member  who  remains  out-of-doors  the  greatest 
number  of  hours  in  the  month  has  his  record  exhibited. 
This  stimulates  a  spirit  of  healthy  emulation.  One 
patient  was  out-of-doors  seven  hundred  and  six  hours 
in  a  month,  an  average  of  nearly  twenty-three  out  of  the 
twenty-four.  Some  of  the  sickest  members  gain  this 
distinction.  The  favorable  cases  that  are  making  rapid 
progress  toward  recovery  infuse  a  spirit  of  hope  in  all. 

"After  the  strength  of  the  member  has  been  tested 
and  increased  by  carefully  prescribed  amounts  he  is 
graduated  and  allowed  to  work.  Home  treatment  has 
one  advantage  over  the  sanatorium  in  the  fact  that  if 
health  has  been  regamed  by  leading  the  out-of-door 
life  at  home,  it  is  easy  to  keep  up  the  hygienic  habits 
after  recovery.    A  place  for  sleeping  out-of-doors  and  a 


302 


TUBERCULOSIS 


Fig.  8o.     An  Emmanuel  Church  Class  Patient  Taking  the  Open 
Air  Treatment  in  a  Back  Yard  of  a  Boston  Tenement. 

reclining  chair  for  resting  in  the  recumbent  posture  are 
still  available.  Our  graduates  continue  to  sleep  out-of- 
doors  or  with  their  heads  in  open  windows." 

We  reproduce  here  a  very  interesting  illustration 
(Fig.  80)  showing  how,  under  seemingly  adverse 
circumstances,  it  has  been  possible  for  an  Emman- 
uel Church  class  patient  to  have  his  outdoor  sleep- 
ing at  night  and  open  air  treatment  during  the 
day.  As  will  be  seen  the  tent  has  been  erected  in 
the  back  yard  of  one  of  the  poorest  districts  of 
Boston.     Nevertheless,  the  patient  has  what  he 


EMMANUEL  CHURCH  WORK  303 

needs — fresh  air  day  and  night,  good  food,  and 
medical  supervision.  But  he  has  something  more 
which  the  Emmanuel  people  have  known  how  to 
provide  and  which  accounts  in  no  small  degree 
for  the  admirable  results  which  they  have  obtained. 
Without  imposing  their  religious  convictions  upon 
any  one,  the  doctors  of  divinity  went  among 
these  patients  and,  assisted  by  friendly  visitors,  in- 
spired them  with  hope  and  comfort ;  talked  to  them 
of  home,  children,  wives,  and  husbands.  Then  the 
friendly  visitors  looked  after  the  wives  or  children, 
mothers  or  sisters  in  the  home.  In  all  instances 
w^hen  the  breadwinner  was  the  invalid,  these  good 
women  took  it  upon  themselves  to  see  that  there 
was  nothing  w^anting  in  that  home  that  was  with- 
out a  breadwinner.  In  other  words,  the  invalids 
and  their  families  were  taken  care  of  bv  the  Em- 
manuel  Church  people  as  long  as  there  was  need 
for  it.  Perhaps,  never  before  in  their  lives  had 
these  individuals  so  much  peace  of  mind,  happi- 
ness, and  contentment  as  when  lying  on  their  re- 
clining chairs  taking  the  rest-cure  in  the  open  air, 
thinking  of  their  well-provided  family  and  their 
prospective  recovery;  and  having  at  the  same  time 
the  assurance  given  to  them  that  employment 
would  be  provided  when  they  were  again  able 
to  work — and  all  this  without  being  away  from 
home.    The  element  of  homesickness,  so  distress- 


304  TUBERCULOSIS 

ing  to  many  sanatorium  patients,  as  well  as  the 
element  of  worry  and  anxiety,  did  not  exist.  All 
these  psychological  factors  are  responsible  for  the 
success  of  the  Emmanuel  Church  movement  as 
far  as  tuberculosis  is  concerned,  as  well  as  tha 
hyo^ienic,  dietetic,  and  fresh  air  treatment. 

I  approve  most  highly  of  such  humanitarian 
work  as  this,  inaugurated  on  the  one  hand  by  a 
doctor  of  medicine  and  on  the  other  by  a  doctor 
of  divinity.  There  is  but  one  word  of  warning 
which  I  feel  in  duty  bound  to  express  in  all 
frankness :  the  seemingly  little  medicinal  treatment 
which  is  needed  in  many  tuberculosis  cases  may 
tempt  the  clergyman  or  layman  to  undertake  the 
treating  of  tuberculous  patients  without  any,  or 
without  a  very  thorough  supervision  or  guidance 
by  medical  men.  If  in  any  disease  the  physician 
is  needed,  it  is  certainly  in  tuberculosis  in  no  mat- 
ter what  stage. 

In  the  preceding  chapter  we  have  spoken  of  the 
duties  of  public  officials,  of  municipal  boards  of 
health,  and  of  physicians;  but  no  matter  how  great 
their  efforts  may  be,  it  will  be  difficult  to  solve  the 
problem  without  the  cooperation  of  private  phi- 
lanthropy. One  of  the  most  successful  ways  to 
work  together  is  doubtless  to  form  a  special  tu- 
berculosis committee  composed  of  representatives 
of  the   local  health  board   and  other  municipal 


CO-OPERATION  305 

departments,  the  clergy,  physicians  particularly 
interested  in  the  tuberculosis  problem,  philan- 
thropic men  and  women,  and  the  representatives 
of  charitable  organizations.  Such  a  committee  the 
author  was  privileged  to  help  form  for  the  City 
of  New  York  in  the  year  1902.  The  following 
is  in  brief  the  purpose  of  this  Committee: 

1.  Research:  Into  the  social,  as  distinct  from  the 
medical,  aspect  of  tuberculosis.  The  study  of  the 
relation  between  the  disease  and  overcrowding, 
infected  tenements,  and  unhealthful  occupations. 

2.  Education:  The  publication  of  leaflets  and 
pamphlets ;  the  giving  of  lectures  with  and  without 
stereopticon  views ;  the  use  of  a  travelling  tubercu- 
losis exhibit  designed  to  emphasize  the  fact  that 
tuberculosis  is  a  communicable,  preventable,  and 
curable  disease;  the  dissemination  of  knowledge 
concerning  the  means  and  methods  to  be  adopted 
for  the  prevention  and  cure  of  tuberculosis. 

3.  Treatment:  The  encouragement  of  move- 
ments for  suitable  public  and  private  sanatoria; 
both  for  advanced  and  for  incipient  cases,  for 
adults  and  for  children,  for  free  care,  and  also  for 
the  care  of  those  who  are  able  to  pay  moderate 
fees. 

4.  Lef!^islation:  An  effort  to  secure  the  enactment 
of  legislation  looking  toward  the  control  of  such 
recognized  causes  of  contagion  as  spitting  in  pub- 


3o6  TUBERCULOSIS 

lie  places,  the  dry  sweeping  of  streets,  the  use  of 
dark  rooms  in  tenements  for  sleeping  purposes,  etc. 
After  seven  years  of  existence,  the  Committee 
on  the  Prevention  of  Tuberculosis  of  the  Charity 
Organization  Society  of  the  City  of  New  York 
could  point  to  the  following  accomplishments, 
which  were  summarized  by  Mr.  Lawrence  Veiller 
for  a  report  for  the  International  Congress  on 
Tuberculosis  which  convened  in  Washington,  D. 
C,  in  the  fall  of  1908.     This  Committee 

1.  Made  the  first  comprehensive  study  of  the  social 

aspect  of  tuberculosis. 

2.  Formtilated  standard  schedules  for  recording  the 

social  history  of  tuberculosis  cases. 

3.  Made  a  comprehensive  study  of  institutions  and 

societies  for  the  treatment  of  tuberculosis  in  the 
United  States  and  Canada — publishing  a  Di- 
rectory of  same  in  270  pages. 

4.  Made  a  careful  study  of  tuberculosis  among  Ne- 

groes in  New  York  City. 

5.  Made  a  comprehensive  investigation  of  conditions 

in  New  York  City  lodging  houses  with  reference 
to  tuberculosis. 

6.  Made  an  investigation  of  conditions  in  the  New 

York  Federal  Post-Office  building  with  reference 
to  tuberculosis. 

7.  Made  an  investigation  of  country  employment  for 

city  consumptives. 


CHARITY  ORGANIZATION  SOCIETY        307 

8.  Made  a  comprehensive  inquiry  into  the  whole  mat- 

ter of  the  reUef  and  care  of  tuberculosis  in  New 
York  City. 

9.  Made  a  thorough  study  of  the  possibilities  of  home 

treatment  of  the  tuberculous  sick  in  New  York's 
tenement  houses. 

10.  In  cooperation  with  the  New  York  Milk  Commit- 

tee, made  a  comprehensive  study  of  bovine  tu- 
berculosis in  New  York  State  and  its  methods  of 
regulation;  and  lastly, 

11.  Made  a  study  in  New  York  City  of  the  prevalence 

of  tuberculosis  among  workers  in  certain  in- 
dustries— based  on  medical  examinations. 

In  the  educational  line,  this  Committee 

1.  Originated    the    plan   for   pubhshin^   tuberculosis 

maxims  on  the  back  of  street  car  transfers — 
50  milHon  a  year  circulated  this  way. 

2.  Distributes  250,000  Circulars  of  Advice  regarding 

tuberculosis  each  year  to  the  public,  through 
Labor  Unions,  Factories,  Department  Stores, 
Settlements,  Churches,  etc. 

3.  Has  given  733  popular  lectures  on  tuberculosis  to 

audiences  of  148,125  people — in  Enghsh,  Yid- 
dish, ItaHan,  Bohemian,  French,  and  German — 
228  lectures  to  78,640  persons  this  year. 

4.  Originated  the  permanent  traveling  Tuberculosis 

Exhibition  as  a  means  of  educating  the  com- 
munity.—Exhibit  shown  throughout  each  year 
in   Settlements,   Churches,   Clubs,  etc.,   and  in 


3o8  TUBERCULOSIS 

stores  on  crowded  thoroughfares — viewed  by 
150,000  people  in  six  weeks  at  one  place  this  year. 

5.  Established  a  weekly  press  service  to  200  news- 

papers in  New  York  State — furnishing  news  mat- 
ter about  tuberculosis  prevention  and  treatment. 

6.  Carried  on  the  first  active  educational  campaign 

among  Labor  Unions — securing  the  cooperation 
of  the  United  Garment  Workers  of  America, 
Central  Eederated  Union,  and  American  Fed- 
eration of  Labor,  etc. 

7.  Organized  a  Committee  on  the  Prevention  of  Tuber- 

culosis among  Negroes  in  New  York  City. 

8.  Issued  a  circular  to  8,000  physicians  against  sending 

consumptives  out  West  or  to  the  country  except 
under  proper  conditions. 

9.  Issued    a    strong    pronouncement    against    ''Con- 

sumption Cures." 

10.  Published  a  comprehensive  book  on  the  prevention 

of  tuberculosis — 388  pages. 

11.  Published  and  distributed  1,000  copies  of  a  report 

on  Bovine  Tuberculosis  in  New  York  State. 

12.  PubHshed  the  first  Directory  of  Institutions  for  the 

treatment  of  tuberculosis  in  the  United  States — 
270  f)ages. 

13.  Published  and  distributed  to  physicians  and  others 

6,000  copies  of  a  report  on  Home  Treatment  of 
Tuberculosis  in  New  York  City. 

14.  Originated  a  plan  of  distributing  art  posters,  with 

tuberculosis  advice  in  them,  in  tenement  homes — ■ 
10,000  distributed  to  Italians. 


CHARITY  ORGANIZATION  SOCIETY       309 
Furthermore, 

1.  It  took  steps  to  bring  about  formation  of  more 

special  tuberculosis  clinics  in  the  dispensaries  of 
New  York  City. 

2.  It  was  also  an  agency  in  New  York  City  to  advocate 

formation  of  special  tuberculosis  clinics  for  chil- 
dren. 

3.  It  took  active  part  in  urging  and  bringing  about  the 

building  of  a  Municipal  Sanatorium — prepared 
and  published  architects'  plans,  which  formed 
basis  of  official  report  to  the  Mayor. 

4.  It  secured  funds  for  special  relief  of  consumptives  in 

their  homes — for  special  diet,  payment  of  rent, 
wage  loss,  clothing,  bedding,  pensions,  etc. — 
$33,496  thus  expended  in  20  months. 

5.  It  brought  about  special  visitation  by  physicians,  of 

Russian  and  Polish  famihes  in  their  homes. 

6.  It  secured  opening  at  night  of  special  tuberculosis 

clinic  for  Negroes.  Colored  nurses'  services 
furnished  by  Committee. 

7.  It  sent  a  selected  number  of  consumptives  out  of 

the  city  for  country  treatment,  and  defrayed 
their  board  and  exoenses. 

8.  It  brought  about  examination  at  special  clinics  of 

children  in  tuberculous  families — defrayed  cost 
of  medical  examinations  of  same. 

9.  It   established   First   Day   Camp   for   tuberculous 

patients  in  New  York  City  on  abandoned  ferry- 
boat "Southfield." 


3IO  TUBERCULOSIS 

10.  It  has  medical  examinations  made  of  workers  in 

different  trades  to  determine  extent  of  tubercu- 
losis— cost  defrayed  by  Committee. 

11.  It  brought  about  establishment  of  District  System 

of  Tuberculosis  Clinics  in  New  York  City  and 
union  of  existing  agencies  in  new  association  of 
tuberculosis  clinics. 

12.  It  formulated  comprehensive  plan  of  hospital,  sana- 

torium, and  dispensary  treatment  for  the  tuber- 
culous sick  in  New  York  City. 

13.  From  time  to  time  it  has  investigated  adequacy  of 

existing  hospital  provision  for  tuberculous  sick 
and  urged  the  authorities  to  meet  it  more  ade- 
quately. 

Regarding  legislation,  this  Committee  has  shown 
the  very  important  part  such  a  group  of  men  and 
women  can  play  by  promoting  just  laws  and  fur- 
thering the  interest  of  consumptives  and  the  pub- 
lic in  general,  and  by  opposing  unjust  and  inhu- 
mane laws: 

1.  It  took  active  part  in  the  legislative  campaign  for 

appropriation  for  completion  of  the  Free  State 
Hospital  at  Ray  Brook. 

2.  It  took  active  part  in  opposing  law,  making  difficult 

the  establishment  of  tuberculosis  sanatoria  in  the 
State. 

3.  It  has  repeatedly  protested  against  legislation  weak- 

ening the  Tenement  House  Laws. 


CHARITY  ORGANIZATION  SOCIETY       311 

4.  It  supported  legislation  authorizing  State  Commis- 

sioner of  Labor  to  require  adequate  ventilation 
in  factories. 

5.  It  supported  legislation  authorizing  appointment  of 

Medical  Inspector  in  the  State  Department  of 
Labor. 

6.  It  formulated  Bill  for  the  Regulation  of  Bovine 

Tuberculosis,  which  served  as  the  basis  for  an 
important  amendment  to  the  Agricultural  Law. 

The  New  York  Charity  Organization  Society  has 
a  committee  under  the  chairmanship  of  Professor 
Theodore  C.  Janeway,  M.  D.,  which  is  for  the  purpose 
of  finding  employment  for  the  handicapped,  including 
tuberculous  invalids  able  to  do  some  work.  The  value 
of  such  a  committee  must  be  obvious  when  one  con- 
siders how  frequent  tuberculosis  is  among  the  laboring 
population. 

Diet  kitchens  which  provide  good,  pure  milk,  free 
of  charge  to  the  destitute  sick,  are  valuable  aids  in 
the  treatment  and  care  of  the  tuberculous  poor.  The 
milk  is  given  to  the  patients  upon  the  written  recom- 
mendation of  the  attending  physician.  The  New 
York  Diet  Kitchen  Association,  under  the  presi- 
dency of  Mrs.  Henry  Willard,  has  now  eight  branches 
throughout  the  city.  The  Association  docs  magnifi- 
cent work  and  deserves  the  support  of  all  those  able 
to  give  it. 

The  Russell  Sage  Foundation,  by  substantial  money 
contributions,  has  been  helpful  in  aiding  the  various 


312  TUBERCULOSIS 

national,  state,  and  local  anti-tuberculosis  agencies  in 
their  educational  propaganda. 

It  was  reserved  to  three  philanthropists  of  our  own 
country  to  found  institutions  for  the  specific  purpose 
of  teaching  physicians  and  training  them  in  tubercu- 
losis science.  Mr.  Henry  Phipps  of  New  York  is  the 
founder  of  the  Phipps  Institute  for  the  Study  and 
Prevention  of  Tuberculosis  in  Philadelphia,  and, 
furthermore,  he  established  the  Phipps  Dispensary  in 
connection  with  the  Johns  Hopkins  Medical  School 
at  Baltimore.  Mr.  John  D.  Rockefeller  established  a 
special  tuberculosis  hospital  in  connection  with  the 
Rockefeller  Institute  in  New  York;  and  Mr.  Andrew 
Carnegie  gave  toward  the  establishment  of  the  Robert 
Koch  Institute  of  Berhn  for  the  Study  of  Tuberculosis, 
the  magnificent  sum  of  $250,000  (1,000,000  marks). 
May  the  examples  given  by  these  three  generous  philan- 
thropists find  emulation  everywhere.  To  create  op- 
portunities to  study  tuberculosis  in  all  its  aspects,  and 
to  send  out  well-trained  physicians,  is,  indeed,  indis- 
pensable if  we  would  wish  to  master  the  disease. 

In  this  connection  it  should  be  said  that  the  scien- 
tific research  work  regarding  tuberculosis  must  be 
encouraged,  and  careful  and  humane  animal  experi- 
mentation should  not  be  opposed.  It  is,  thanks  to 
animal  experimentation  that  many  of  our  infectious 
diseases  have  now  become,  not  only  less  frequent,  but 
more  surely  and  rapidly  cured.  Anti-vivisectionists 
should  remember  that  scientific  experimenters  never 
purposely  torture  animals  and  that,  for  example,  the 


VIVISECTION  313 

horses  from  which  antitoxinc  for  diphtheria  is  produced, 
do  not  suffer.  Let  these  good  people,  furthermore,  re- 
call that  it  is  to  the  experiments  on  a  few  hundred 
guinea  pigs  and  rabbits  that  the  discovery  of  antitoxinc 
is  due,  and  that  the  consequence  is  that  the  mortality 
from  diphtheria  has  been  reduced  from  seventy  or 
seventy-five  per  cent  to  five  or  six  per  cent.  This  means 
that  ninety-four  to  ninety-five  diphtheritic  children  are 
saved  out  of  every  hundred,  instead  of  twenty-five  or 
thirty  as  formerly.  Let  every  American  mother  re- 
member these  facts  when  she  is  asked  to  aid  in  the 
protests  against  scientific  vivisection. 

It  may  seem  ungracious  to  suggest  to  a  philan- 
thropist what  it  might  be  best  for  him  to  do  in  his 
desire  to  help  his  fellow-men;  but  when  one  pe- 
ruses the  varied  activities  of  a  charity  organization 
society,  such  as  those  enumerated  above,  one  can 
not  help  thinking  that  from  a  concerted  action  of 
the  philanthropists  and  such  a  society,  the  greatest 
benefit  for  the  tuberculosis  cause  must  be  derived. 

The  ofificers  of  an  organized  charity  organization 
society  will  know  where  model  tenement  houses 
are  most  needed,  and  what  kind  of  tuberculosis 
institution  is  best  fitted  to  meet  existing  demands. 
Thus,  for  example,  at  the  time  of  writing  this  book 
there  is  in  the  City  of  New  York  the  greatest  need 
of  taking  care  of  advanced  cases  of  tuberculo- 
sis who  constitute  centers  of  infection  in  the  ten- 


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SANATORIUM  TREATAIENT  31^ 

ement  houses;  and  an  urgent,  crying  need  of  the  es- 
tabhshment  of  sanatoria  for  tuberculous  children 
for  whom,  with  the  exception  of  Sea  Breeze,  there 
is  now  almost  no  provision.  I  am  convinced  that 
philanthropists  can  not  render  greater  service  to 
the  anti-tuberculosis  cause  at  this  time  than  by 
helping  the  New  York  Tuberculosis  Committee  in 
its  efforts  to  suppress  centers  of  infection,  and  in 
its  endeavors  to  prevent  the  tuberculous  child  of 
to-day  from  becoming  the  consumptive  adult  of 
to-morrow. 

With  the  help  of  the  clergy,  of  philanthropists, 
of  charitable  individuals,  and  charity  organizations, 
a  great  deal,  of  course,  can  be  done  in  the  direction 
of  establishing  sanatoria  for  tuberculous  adults  and 
children,  hospitals  for  the  advanced  cases,  day 
camps,  night  camps,  and  tuberculosis  classes.  Of 
the  economic  value  of  sanatorium  treatment  in 
tuberculosis  we  have  spoken  in  Chapter  VH.  By 
means  of  the  sanatorium  treatment,  that  is  to  say, 
the  treatment  of  the  tuberculous  in  institutions  es- 
pecially established  and  equipped  for  the  purpose, 
eighty  to  ninety  per  cent  of  incipient  cases  are 
cured,  or  their  disease  sufficiently  arrested  so  that 
they  can  again  become  breadwinners.  It  has  been 
demonstrated  that  with  the  aid  of  the  sanatorium 
treatment  patients  can  be  cured  in  all  climates;  and 
this  is  very  important  when  we  consider  that  tuber- 


3i6 


TUBERCULOSIS 


Fig.  82.     Adirondack  Cottage  Sanatorium.     Piazza  of  the  New 
Medical  and  Reception  Pavilion. 


culosis  is  a  disease  which  is  prevalent  everywhere, 
and  that  it  would  be  inexpedient  and  unwise  to 
send  every  patient  to  what  was  formerly  known  as 
a  ^'specific  climate"  particularly  effective  in  the 
treatment  of  tuberculosis. 

There  are  now  throughout  the  civilized  world  any 
number  of  private  and  public  sanatoria  situated 
in  various  altitudes  and  latitudes.  The  United 
States  has  not  been  behind  in  establishing  insti- 
tutions of  this  kind.  In  Chapter  VII  we  gave  a 
complete  list  of  existing  state  sanatoria.    The  num- 


SANATORIUM  TREATMENT 


317 


Fig.  83.     Manila  C.  Wheeler  Cottage  of  the  Adirondack  Cottage 
Sanatorium,  Trudeau,  New  York. 

ber  of  private  institutions  in  the  United  States  as 
well  as  in  other  countries  is,  of  course,  many 
times  greater,  and  their  number,  I  am  happy  to 
state,  is  constantly  on  the  increase.  According  to 
the  records  of  Professor  Livingston  Farrand,  the 
Secretary  of  our  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis,  before  the 
year  1905  there  existed  throughout  the  United 
States  115  sanatoria  and  special  tuberculosis  hos- 
pitals. In  the  year  1905,  15  of  such  institutions 
were  established;  in  1906,  17;  in  1907,  35;  in  1908, 
71;  and  during  the  first  three  months  of  1909,  39; 
so  that  we  have  to-day  in  the  United  States  all 
told  289  institutions  where  patients  arc  housed, 


31^ 


TUBERCULOSIS 


|s/9/XUF=if^      C  o -r -r  >K  C3- El 


— ^-  O-  P?OLjrvi  CD 


OnC  i^ooT. 


Fig.  84.     Adirondack  Cottage  Sanatorium,  Ground   Plan  of 
McAlpin  Cottage. 

boarded,  and  kept  under  constant  medical  super- 
vision. These  institutions  are  justly  called  closed 
establishments,  that  is  to  say,  they  are  exclusively 
consecrated  to  tuberculosis  cases,  and  no  other 
class  of  patients  are  received  there. 

I  can  only  reproduce  here  a  fcv^  illustrations  of 
the  many  useful  private,  philanthropic,  and  semi- 


SANATORIUM  TREATMENT  321 

philanthropic  institutions  in  this  and  many  foreign 
countries;  all  of  them  are  doing  a  vast  amount  of 
good,  not  only  as  curative  but  also  as  educational 
agencies.    (Figs.  81  to  104.)  ^ 

I  wish  it  to  be  distinctly  understood  that  in 
selecting  the  institutions  for  illustration  I  was  not 
guided  by  any  preference  for  one  or  the  other, 
but  simply  by  a  desire  to  give  an  idea  of  the 
various  types  of  construction  now  in  use  for  the 
treatment  and  care  of  consumptives  in  the  various 
climes  and  sections  of  our  own  and  other  coun- 
tries. It  may  be  said  that  in  Europe  the  one- 
house  system  is  in  favor,  while  in  the  United 
States  the  cottage  system  with  from  four  to  five 
patients  is  more  universally  adopted  for  private 
institutions.  The  larger  private  sanatoria  have, 
as  a  rule,  also  an  infirmary  where  patients  who 
need  special  care  or  supervision  are  temporarily 
housed. 

It  is  the  constant  outdoor  life  in  pure  air,  the 
abundant  but  carefully  regulated  diet,  and  the  con- 
stant medical  guidance  and  supervision  which  the 
patient  receives  in  the  sanatorium  that  has  achieved 

1  For  complete  and  detailed  information  concerning  other  philan- 
thropic, semi-philanthropic,  and  private  sanatoria,  the  reader  is  re- 
ferred to  the  directory  of  institutions  of  the  United  States  and 
Canada,  compiled  under  the  direction  of  the  National  Association 
for  the  Study  and  Prevention  of  Tuberculosis  by  means  of  the 
Russell  Sage  Foundation. 


SANATORIUM  TREATMENT  323 

such  wonderful  results.  The  patient  sleeps  out- 
doors at  night;  he  rests  in  the  rechning  chair  tak- 
ing what  is  known  as  the  ''cure"  during  the  day; 
the  amount  of  exercise  is  prescribed  by  the  physi- 
cian so  that  it  will  do  him  good  and  not  harm;  the 
slightest  intercurrent  trouble  is  reported  to  the  phy- 
sician. 

In  the  sanatorium  the  precautions,  concerning 
the  expectoration  and  all  that  appertains  to  the 
prevention  of  infection,  are  so  thorough  that  it  may 
be  said  one  is  more  secure  from  contracting  tuber- 
culosis within  its  precincts  than  anyw^here  else. 
The  contracting  of  tuberculosis  by  physicians  and 
attendants  in  the  sanatorium  is  of  the  rarest  oc- 
currence. 

This  brings  us  to  the  very  interesting  topic  of  the 
medical  and  social  mission  of  the  sanatorium  for 
consumptives.  Of  its  curative  mission  we  have 
already  spoken.  The  educational  mission  of  san- 
atoria for  consumptives  is  so  important  that,  ac- 
cording to  some  authorities,  it  overshadows  all 
others.  In  the  sanatorium  the  patient  is  taught 
how  to  dispose  of  his  sputum  and  how  to  guard 
against  drop  infection.  He  is  taught  how  to  cough, 
when  to  cough,  and  when  not  to  cough.  He  learns 
to  live  in  fresh,  pure  air  by  day  and  by  night.  He 
learns  w^hen  to  eat,  how  to  cat,  and  ^^•hat  to  eat. 
He  learns  how  to  breathe,  how  to  exercise,  and  when 


324 


TUBERCULOSIS 


Fig.  88.  Edward  Sanatorium  at  Naperville,  Near  Chicago.  For  In- 
cipient Cases  Only.  Dr.  Sachs  Is  the  Visiting  Physician,  a  Nurse 
Is  in  Charge  of  the  Institution.  Ten  Beds  Are  Maintained  by  the 
Nurses'  Association.      Rates  $10.00  per  Week. 

to  exercise,  and  what  to  do  in  order  not  to  catch 
cold.  He  learns  not  to  be  unduly  alarmed  at  the 
sight  of  ])lood  in  the  sputum.  He  learns  to  be 
hopeful  and  cheerful,  and  that  he  must  labor  to  get 
well.  When  he  returns  home  cured  or  improved, 
he  will  impart  all  his  knowledge  to  his  family, 
friends,  and  neighbors,  and  become  a  hygienic  fac- 
tor in  the  community. 

To  the  public  at  large  the  well-equipped  sana- 
torium teaches  that  phthisiophobia  is  as  unjust  as 


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it  is  cruel,  and  that  a  patient  who  takes  care  of 
his  expectoration  and  guards  against  droplet  in- 
fection is  as  safe  an  individual  to  associate  with 
as  any  one.  It,  furthermore,  teaches  that  sanatoria 
for  consumptives  are  no  danger  to  the  neighbor- 
hood. The  statistics  of  the  two  villages  Goerbers- 
dorf  and  Falkenstein,  where  five  of  the  largest  Ger- 
man sanatoria  have  been  located  for  many  years, 
show  that  the  mortality  from  tuberculosis  has  been 
reduced  by  one-third  from  what  it  was  before  the 
estabhshment  of  these  institutions. 

In  Rutland,  Alass.,  w^here  the  ^Massachusetts 
State  Sanatorium  is  located,  during  the  six  years 
after  the  opening  of  the  sanatorium  there  have  been 
only  eight  deaths  from  tuberculosis  annually  with 
an  increased  population,  while  prior  to  the  estab- 
lishment of  the  sanatorium,  among  a  smaller  num- 
ber of  people,  they  had  fourteen  deaths  annually 
from  this  disease.  Almost  as  marked  a  reduction 
has  been  reported  by  Dr.  Elliott  of  Gravenhurst, 
Canada,  where  sanatoria  for  early  as  well  as  for 
advanced  cases  of  tuberculosis  have  been  estab- 
lished for  nearly  ten  years. 

Besides  educating  individual  patients  and  the 
community  at  large,  the  sanatorium  offers  excel- 
lent opportunities  for  young  physicians  who  enter 
there  as  assistants  to  become  expert  diagnosticians 
^.nd  experienced  phthisiotherapeutists.  The  knowl- 


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SANATORIUM  TREATMENT  329 

edge  gained  by  a  year  or  two  of  service  in  a  san- 
atorium for  consumptives  will  make  the  young 
practitioner,  if  he  does  not  wish  to  continue  in  in- 
stitutional work,  an  ideal  family  physician,  well 
equipped  to  treat  the  most  frequent  and  prevalent 
of  all  chronic  diseases. 

The  trained  nurse,  taking  a  post-graduate  course 
in  a  sanatorium  for  consumptives,  will  gain  val- 
uable experience  which  she  can  utilize  advanta- 
geously after  she  returns  to  her  private  work  as  a 
general  nurse. 

The  last  mission  of  the  sanatorium  is  to  help,  to 
better,  to  uplift,  and  to  harmonize  social  differences. 

There  is  no  denying  the  sad  fact  that  the  exces- 
sive use  of  alcohol  is  to  be  found  among  the  rich  as 
well  as  among  the  poor  of  nearly  all  nations.  In 
a  sanatorium,  the  regular  mode  of  hfe,  the  strict 
prohibition  of  alcoholic  drinks,  except  in  rare  in- 
stances for  medicinal  purposes,  may  therefore  wtII 
be  considered  an  important  social  factor  in  help- 
ing to  reduce  that  curse  of  so  many  civilized  na- 
tions— alcoholism.  The  belief  that  alcohol  is  a 
preventive,  or  a  sure  cure  for  consumption,  is  not 
confined  to  any  one  country.  I  have  met  with  this 
erroneous  conception  among  the  people  of  Europe 
as  well  as  of  America,  and  it  is  not  always  exclu- 
sively to  be  found  among  the  so-called  submerged 
or  ignorant  poor. 


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SANATORIUM  TREATAIENT  331 

The  regularity  of  life  in  a  well-conducted  san- 
atorium also  tends  to  make  the  careless  individual 
a  careful  one,  the  thoughtless  a  more  thoughtful. 
In  a  people's  sanatorium  the  uneducated  patient 
is  given  an  opportunity  to  increase  his  knowl- 
edge, and  the  one  who  has  had  no  opportu- 
nity of  acquiring  good  manners  will  be  taught 
them. 

Nearly  all  the  European  and  American  sanatoria 
offer  intellectual  and  educational  advantages  to 
their  inmates.  The  sanatorium  often  confers  bene- 
fits even  ethically  and  morally.  A  prolonged  so- 
journ in  such  an  institution  will  probably  always 
leave  a  deep  impression  on  the  social  views  of  the 
consumptive  individual.  Be  he  ever  so  rich,  aristo- 
cratic, or  even  indifferent  to  his  fellow-men,  he  will 
become  more  democratic  and  more  benevolent;  he 
will  feel  more  for  his  comrades  than  he  has  prob- 
ably ever  felt  before.  There  often  appears  a  spirit 
of  the  truest  charity  among  sanatorium  inmates, 
and  it  was  my  good  fortune  to  witness  such  a  man- 
ifestation among  well-to-do  and  aristocratic  tuber- 
culous patients  at  Falkenstein  while  I  had  the 
honor  of  serving  as  assistant  to  my  regretted  and 
immortal  teacher,  Geheimrath  Dettweiler.  As  a 
result  of  the  deep  feeling  for  the  suffering  of  the 
consumptive  poor  outside  of  the  sanatorium,  who 
were  deprived  of  the  care  and  comfort  of  institu- 


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333 


Fig.  94.  New  Mexico  Cottage  Sanatorium,  Silver  City,  N.  M. 
Private.  For  Pulmonary  and  Laryngeal  Tuberculosis  at  Curable 
Stage.     Rate:  $83.00  per  Month. 

tional  treatment,  these  well-to-do  patients  contrib- 
uted largely  to  the  estabhshment  3f  the  first  people's 
sanatorium  in  Germany,  now  located  at  Rupperts- 
hain.  Later,  this  institution  was  largely  bene- 
fited by  the  generous  bequest  of  a  patient  who, 
during  his  last  few  months,  had  received  the  tender 
care  of  the  physicians  and  devoted  nurses  at  Fal- 
kenstein.  Our  own  beloved  Trudeau  who,  twenty- 
five  years  ago,  in  the  wilderness  of  the  Adirondack 
Mountains,  started  with  one  little  cottage  and  two 
poor  patients,  owes  the  existence  of  the  now  great 
and  justly  celebrated  Adirondack  Cottage  Sana- 
torium (Fig.  78),  comprising  about  thirty  cottages, 
with  a  large  administration  building,  infirmary, 
library,  and  church,  to  liberal  contril^utions  from 
rich  and  grateful  tuberculous  patients. 


334 


TUBERCULOSIS 


Fig.  95.     Nordrach  Ranch,  Colorado  Springs,  Colo.     For  First  and 
Second  Stages.     Private.     Rates:  $60.00  to  $65.00  per  Month. 


Besides  the  sanatorium,  the  special  hospital,  and 
the  dispensary,  there  are  other  methods  which  of 
late  years  have  proved  efficacious  in  the  care  of 
tuberculous  patients,  and  particularly  of  the  con- 
sumptive poor.  We  refer  to  the  day  camp,  the 
night  camp,  and  the  class  method  already  de- 
scribed in  connection  with  the  Emmanuel  Church 
work. 

The  day  camp  idea  originated  in  Germany  in 
1900,  under  the  name  of  ''Walderholungsstatte," 
which  might  be  freely  translated  as  a  health  station 
in  the  forest.     The  first  day  camp  for  consump- 


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Fig.  97.     A  Two  Room  Compartment  Tent  of  the  Star  Ranch, 
Colorado  Springs,  Colo. 

tives  in  the  United  States  was,  I  believe,  estab- 
lished by  the  Boston  Association  for  the  Rehef  and 
Control  of  Tuberculosis. 

The  purpose  of  such  a  day  camp,  which  is 
usually  located  in  the  healthiest  locahty  of  a  city, 
preferably  in  wooded  regions,  is  to  receive  patients 
during  the  daytime,  to  provide  the  consumptive 
patient  with  a  comfortable  chair  for  the  rest-cure 
in  a  pleasant  and  sheltered  spot,  and  to  provide  him 
with  one  or  two  substantial  meals  and  milk  and 
eggs  between  times.  The  patients  are,  of  course, 
taught  to  be  exceedingly  careful  with  their  expecT 
toration  and  instructed  in  all  other  hygienic  meas- 
ures essential  for  their  own  and  their  associates' 


SANATORIUM  TREATMENT 


337 


Fig.  98.     Muskoka  Cottage  Sanatorium,  Gravenhurst,  Canada. 


well-being.  A  physician  and  nurse  supervise  the 
treatment  and  care. 

It  was  not  only  in  Boston  that  the  first  day  camp 
was  estabhshed,  but  to  the  city  of  Boston  also  be- 
longs the  credit  of  having  established  the  first  mu- 
nicipal day  camp. 

Under  the  auspices  of  the  Red  Cross  a  number 
of  day  camps  for  the  tuberculous  have  since  been 
established  in  Washington,  Schenectady,  Albany, 
New  York,  etc.  Of  one  of  them,  located  on  the 
roof  of  the  Vanderbilt  Clinic,  we  take  pleasure  in 
reproducing  an  interesting  photograph.    (Fig.  99.) 


33^ 


TUBERCULOSIS 


Fig.  9y.     Red  Cross  Day  Camp  on  the  Roof  of  the  Vanderhilt 

Clinic. 

Of  the  educational  value  of  such  a  day  camp 
there  can  be  no  doubt.  For  cases  for  which  no 
places  in  sanatoria  can  be  found,  it  offers,  at  least, 
a  temporary  substitute  for  sanatorium  treatment. 
Of  equally  great  value  is  it  as  a  temporary  sojourn 
for  a  patient  discharged  from  a  sanatorium,  but  in 
need  of  after-treatment. 

To  the  best  of  my  knowledge,  the  credit  of  the 
night  camp  idea  belongs  to  Dr.  William  Charles 
White,  medical  director  of  the  Tuberculosis  League 
in  Pittsburg,  who  first  proposed  it  to  the  profession. 
Of  these  latter  institutions  we  have  as  yet  but  very 


340 


TUBERCULOSIS 


Fig.  ioi.    Sanatorium  Falkenstein  near  Frankfort  on  the  Main,  with 
Ruin  of  Falkenstein  Castle  in  the  Background.       Private. 

few  in  this  country;  still,  it  is  my  firm  conviction 
that  night  camps  do  as  much  good  as  day  camps. 
Many  a  tuberculous  patient  is  obliged  to  work  for 
his  own  maintenance  or  the  support  of  his  family. 
Upon  the  advice  of  his  physician  he  may  have 
changed  his  indoor  work  for  an  outdoor  occu- 
pation, yet  what  good  does  it  do  him  if  he  is 
obliged  to  sleep  in  an  unsanitary  tenement  or  lodg- 
ing house  ?  And  to  what  danger  is  not  his  family 
exposed  when  they  are  numerous  and  obliged  to 
live  in  close  proximity  with  the  sufferer? 

I  am  convinced  that  the  greatest  number  of  in- 
fections originate  in  the  sleeping  rooms  of  our  con- 
sumptive tenement  house  dwellers,  and  at  night- 


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342  TUBERCULOSIS 

time.  It  is  then  that  the  consumptive  member  of 
the  family  unconsciously  expels  the  bacilliferous 
droplets  during  the  cough,  which  render  the  at- 
mosphere infectious.  Fearing  to  have  the  other 
members  of  the  family  feel  uncomfortable  or  cold, 
he  will  consent  to  have  the  windows  closed  at 
night,  or  close  them  himself  in  spite  of  the  doctor's 
injunction  to  keep  them  open. 

Through  the  night  camp,  the  family  of  the 
consumptive  will  be  protected  and  he  himself 
assured  of  a  good  bed  in  a  well-aired  room  or 
shack. 

In  Canada  there  exists,  under  the  management 
of  Dr.  Arthur  J.  Richer,  an  institution  in  which 
individuals  who  for  one  reason  or  another  are  not 
strong,  either  because  they  are  just  recovering  from 
pleurisy,  pneumonia,  or  grippe,  overworked  or 
predisposed  by  heredity,  are  received  and  treated 
with  a  view  of  preventing  a  possible  development 
of  tuberculosis.  I  have  given  to  that  institution 
the  name  preventorium  and  it  would  seem  to  me 
an  admirable  idea  if  these  preventoria  were  to  be 
multiplied  throughout  the  world.  They  certainly 
would  constitute  a  mighty  factor  in  the  crusade 
against  tuberculosis. 

It  must  be  evident  that  to  carry  out,  in  a  city  like 
New  York,  such  class  methods  as  have  been  de- 
scribed in  this  chapter,  one  will  encounter  a  great 


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344  TUBERCULOSIS 

many  difficulties  which  are  easily  surmountable 
in  a  smaller  community.  Outdoor  sleeping  on 
a  veranda,  or  in  a  yard,  or  even  on  the  roof  under 
present  conditions,  is  practically  impossible  in  a 
large  city.  After  much  experimenting  I  succeeded 
in  getting  a  fair  substitute  in  the  window-tent, 
illustrated  in  Chapter  V  (Fig.  21);  but  a  window- 
tent  is,  of  course,  not  quite  equal  to  actual  out- 
door sleeping,  as  the  window  itself  may  not  always 
have  access  to  the  best  of  fresh  air,  and  the  tent 
does  not  provide  sufficient  circulation  in  hot 
weather. 

The  class  method,  furthermore,  can  only  be 
successful  when  the  patients  comprising  "a  class" 
do  not  live  too  far  apart,  and  when  they  can  be 
visited  and  supervised  by  a  nurse,  and  whenever 
necessary,  by  a  physician.  Thus,  the  ideal  for 
class  method  treatment  w^ould  be  a  house  espe- 
cially built  and  constructed  for  the  purpose;  in 
other  words,  a  house  where  tuberculous  patients 
could  have  the  best  sanitary  arrangements,  with 
balconies  for  outdoor  sleeping,  and  the  building  be 
constructed  in  every  way  to  answer  the  particular 
purpose  of  caring  for  families  with  tul)erculous 
invalids.  My  distinguished  colleague.  Dr.  Henry 
L.  Shively,  had  the  good  fortune  to  find,  in 
Mrs.  Wm.  K.  Vanderl^ilt,  Sen.,  a  philanthropic 
lady  willing  to  carry  out  the  plans  for  such  sani- 


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346 


TUBERCULOSIS 


Fig.  105.     The  Proposed  Shively  Sanitary  Tenements;    Street  View. 

Built  by  Mrs.  Wm.  K.  Vanderbilt,  Sr. 

Henry  Atterbury  Smith,  Architect. 

tary  tenements,  which  will  soon  be  erected  in  this 
city. 

I  am  indebted  to  him  for  the  accompanying 
photographs  (P'igs.  105,  106)  of  what  will  be  known 
as  the  Shively  Sanitary  Tenements,  and  which  will 
occupy  the  center  of  the  block  on  Avenue  A,  be- 
tween 78th  and  79th  Streets. 

Each  of  these  four  tenements  will  be  built  in  the 
form  of  a  hollow  square,  with  a  court  30  by  31  feet 


SANITARY  APARTMENTS  347 

in  the  center,  which  will  be  decorated  with  turf  and 
flowers.  To  enter  an  apartment  the  tenants  will 
have  to  go  through  the  archw^ay  leading  into  the 
court,  and  then  up  one  of  the  four  staircases  built 
in  the  corners  of  the  court.  The  staircases  will 
be  open  to  the  air  and  will  run  to  the  roof,  and 
every  apartment  w^ill  open  directly  off  the  staircase. 
This  will  give  each  of  them  a  separate  front  door. 

On  the  roofs  will  be  erected  comfortable  loggias. 
Wind-breaks  of  glass  will  be  set  up  on  the  north 
side.  The  floors  will  be  tiled.  Shrubs  will  make 
the  place  bright  and  steamer  chairs  will  be  set  ready 
for  the  tenants.  Toilets  will  also  be  provided  for 
men,  women,  and  children. 

It  is  hoped  by  this  means  to  encourage  the  open 
air  life  of  the  people  to  the  utmost  extent.  They 
will  be  able  to  enjoy  fresh  air  without  going  to 
institutions,  and  a  great  deal  of  expense  will  be 
thereby  saved  to  them. 

Every  apartment  is  to  be  provided  with  a  bal- 
cony. The  tenements  are  to  be  six  stories  high,  and 
a  row  of  balconies  is  to  be  erected  for  each  story. 
To  give  access  to  them,  the  windows  will  be  built 
in  three  sections,  so  as  to  open  from  the  floor  to  the 
ceiling.  Tenants  may  sleep  out  on  them,  or,  if  the 
windows  are  thrown  open  to  the  top,  the  room  will 
be  practically  part  of  the  balcony. 

To  secure  the  proper  ventilation  of  the  courts 


Fig,  ig6.     The  Proposed  Shively  Sanitary  Tenements;  Court  View, 
Showing  Open  Staircases. 


SANITARY  APARTMENTS  349 

inside  the  tenement  houses,  a  passage  will  be  cut 
through.  For  the  ventilation  of  the  rooms,  it  is 
planned  that  every  apartment  shall  have  windows 
opening  on  to  both  the  interior  court  and  the  exte- 
rior of  the  tenement  house.  By  this  means  it  will 
be  possible  to  obtain  a  regular  stream  of  air  through 
an  apartment  at  any  time.  The  apartments  will  be 
from  two  to  five  rooms  each.  They  will  conform 
with  the  tenement  house  regulations  and  contain 
from  70  to  120  square  feet  each.  It  is  hoped  that 
it  will  be  possible  in  every  case  to  install  a  bath. 
Gas  rather  than  coal  ranges  will  be  provided  in 
order  to  get  rid  of  the  trouble  in  handling  ashes. 

With  the  aid  of  the  Shively  tenement  homes,  it 
seems  certain  to  me  that  the  class  method  of  treat- 
ment as  conceived  and  so  successfully  carried  out 
by  Dr.  Pratt,  can  very  well  be  imitated  in  New 
York.  It  was  suggested  to  me  by  another  philan- 
thropic lady,  interested  in  tuberculosis  work,  that 
it  would  be  a  good  idea  to  have  in  each  tu- 
berculosis dispensary  district  of  a  great  city  one 
or  two  of  such  sanitary  tenements,  and  to  in- 
duce as  many  as  possible  of  the  dispensary  pa- 
tients to  reside  in  these  ideal  homes.  If  the 
rent  in  these  sanitary  tenements  should  be  higher 
than  in  the  average  tenement  house,  it  would 
probably  be  a  judicious  expenditure  on  the  part 
of    charitable    institutions    and     charitable    indi- 


350  TUBERCULOSIS 

viduals  to  pay  the  difference  as  an  inducement 
for  tuberculous  patients  to  occupy  these  apart- 
ments. The  tuberculous  inhabitants  of  each  open 
air  tenement  house  could  constitute  a  class,  and 
the  supervision  of  physician  and  nurse,  when  all 
the  patients  are  under  one  roof,  would  certainly  be 
easy  and  at  the  same  time  most  efficacious. 

It  would  seem  that  these  open  air  tenements 
might  almost  solve  the  problem  for  the  early 
cases  among  workers  in  cities,  if  we  could  only 
have  enough  of  them;  but  we  must  not  forget  the 
advanced  cases.  The  incurable  and  refractory 
patients  must  be  segregated,  else  they  are  a 
menace  to  their  families  and  the  community  as 
well.  Institutions  for  them  are  urgently  needed 
in  our  country  at  present.  Professor  Edward  T. 
Devine,  in  his  new  book  "Misery  and  its  Causes," 
pleads  eloquently  for  them,  and  in  recent  addresses 
before  our  National  Anti-tuberculosis  Association 
the  Hon.  Homer  Folks,  Ex-Commissioner  of  Chari- 
ties, and  Professor  Wm,  H.  Welch  stated  that  the 
greatest  need  in  America  at  this  time  was  for  such 
institutions.  Dr.  Welch  said  that  in  the  opinion 
of  Professor  Koch  and  Professor  Newsholme  the 
marvelous  reduction  in  tuberculosis  in  England 
and  Scotland  (Glasgow  42%)  was  largely  due  to 
the  institutional  segregation  of  advanced  tubercu- 
lous cases. 


CHAPTER  XI 

THE  DUTIES  OF  THE  PEOPLE  IN  THE  COMBAT 
AGAINST  TUBERCULOSIS 

''The  people  have  recognized  their  true  foe  in 
tuberculosis  and  are  stirring  to  the  combat  through- 
out the  civilized  world."  These  significant  words 
recently  spoken  in  an  address  before  a  large  anti- 
tuberculosis gathering,  by  the  foremost  authority 
in  American  pathological  science,  Professor  Wil- 
liam H.  Welch  of  Johns  Hopkins  University  of 
Baltimore,  are  indeed  encouraging. 

The  opportunities  for  every  layman  to  learn 
something  of  what  he  should  know  about  tubercu- 
losis are  certainly  not  lacking.  Literature  abounds, 
daily  papers  often  speak  of  it,  and  lectures  are 
given  under  the  auspices  of  tuberculosis  commit- 
tees, boards  of  education,  and  health  boards. 
These  lectures  are  always  free,  and  upon  a  request 
addressed  to  any  board  of  health,  it  is  not  difficult 
to  get  Hterature  and  information. 

The  one  thing  which  the  people  at  large  should 
realize  above  all  others  is,  that  it  is  necessary  to 
seek  the  advice  of  a  physician  at  the  earliest  possi- 

351 


352  TUBERCULOSIS 

ble  moment  in  a  tuberculous  affection.  If  he  is 
too  poor  to  pay  for  a  private  consultation,  there 
are  in  every  city,  or  if  not  there  ought  to  be,  tu- 
berculosis dispensaries  for  the  poor  to  which  the 
patient  should  apply. 

To  enable  even  a  layman  to  recognize  the  early 
signs  of  the  disease,  I  would  say  that  any  or  all  of 
the  following  symptoms  may  be  present  in  the  be- 
ginning of  a  pulmonary  tuberculosis:  A  long  con- 
tinued cough  or  hoarseness ;  loss  of  flesh ;  flushes  or 
pallor  in  the  face;  feverish  sensation  in  the  after- 
noon; occasional  night-sweats;  a  chilly  sensation 
every  morning;  a  loss  of  appetite;  sometimes  a 
little  streak  of  blood  in  the  expectoration ;  loss  of 
strength  manifesting  itself  in  getting  tired  easily; 
frequent  colds;  a  perceptible  quickening  of  the 
heart-beats  after  slight  exertion;  a  little  change  in 
disposition,  at  times  an  increased  irritability  or  a 
feeling  of  depression;  a  disinclination  to  pursue 
certain  work  which  the  individual  formerly  loved 
to  do,  or  even  a  disinclination  to  pleasures  which 
were  formerly  enjoyed.  I  do  not  mean  that  any 
one  should  be  frightened  on  discovering  any  of 
these  symptoms  and  imagine  that  he  has  the  rest 
of  them.  wSome  of  them  may  be  present,  and  on 
examination  no  tuberculosis  may  be  found.  It  is 
then  all  the  better  for  the  patient;  but  when  any 
of  these  svmptoms  are  present,  or  persist  at  all, 


SYMPTOMS  OF  TUBERCULOSIS  353 

they  should  be  considered  a  warning  sign,  and  it 
is  always  best  in  such  a  case  to  consult  a  physi- 
cian. It  can  not  be  said  too  often  that  the  earlier 
the  tuberculous  patient  submits  himself  to  proper 
treatment,  the  greater  are  his  chances  for  recovery. 
One  more  point  regarding  early  symptoms  must 
be  mentioned;  namely,  that  cough  is  not,  as  is 
often  considered  by  laymen,  an  ever  present  symp- 
tom in  early  tuberculosis.  It  may  be  entirely  ab- 
sent in  the  beginning. 

The  public  at  large  should  know  that  the  disease 
is  preventable  and  curable.  What  we  have  en- 
deavored to  teach  in  Chapter  II  to  those  living 
with  the  patient,  should  really  be  known  by  all  peo- 
ple, for  we  can  never  tell  how  soon  we  may  have  a 
tuberculous  patient  in  our  midst.  In  spite  of  the 
reduction  in  mortality  since  the  recent  active  work 
against  this  disease,  still  out  of  every  seven  deaths 
one  is  due  to  tuberculosis,  which  means  that  in 
the  United  States  about  200,000  individuals  die 
annually  from  the  white  plague.  In  the  world  at 
large,  one  individual  dies  every  three  seconds  of 
one  form  of  tuberculosis  or  another.  The  most 
frequent  is,  of  course,  the  pulmonary  type,  or 
consumption. 

In  Chapter  II  we  have  emphasized  the  fact  that 
tuberculosis  is  very  rarely  directly  hereditary; 
but  that  what  is  often  transmitted  by  tuberculous 


354  TUBERCULOSIS 

parents  is  a  weakened  system  or  physiological 
poverty.  We  have  already  stated  that  by  proper 
training  a  child  born  under  such  conditions  may 
grow  up  to  become  a  strong,  healthy  man  or 
woman.  Nevertheless,  it  is  evident  that  tubercu- 
lous individuals  ought  not  to  marry,  and  when 
tuberculosis  develops  in  a  married  couple  it  is  best 
that  they  should  have  no  children.  The  child  con- 
ceived  and  born  while  the  mother  is  suffering  from 
pulmonary  tuberculosis  in  the  advanced  stages,  has 
little  chance  for  life ;  or,  at  least,  a  great  deal  less 
than  in  a  case  where  the  mother  has  been  afflicted 
with  the  disease  only  in  the  incipient  stage.  The 
same  is  perhaps  true  even  when  the  father  is  the 
tuberculous  parent.  But  whichever  it  may  be,  the 
father  or  the  mother,  the  work  to  overcome  the 
predisposition  to  tuberculosis  in  infancy  and  child- 
hood must  begin  before  the  child  is  born.  The 
mother  who  fears  the  transmission  of  a  tuberculous 
predisposition  to  her  child  must,  throughout  the 
child-bearing  period,  live  in  the  best  possible  hy- 
gienic environment,  in  the  purest  air  obtainable 
and,  from  the  earliest  recognition  of  her  condition, 
refrain  from  wearing  restricting  garments.  She 
should  often  breathe  deeply  and,  in  fact,  she 
should  take  regular  breathing  exercises  until  the 
desire  for  deep  breathing  becomes  natural  to  her. 
The  kind  of  breathing  exercise  which  a  pregnant 


PREVENTION  OF  TUBERCULOSIS         355 

woman  can  take  without  fear  of  harm  in  her  con- 
dition, but  which  on  the  contrary  will  benefit  her, 
is  the  following:  She  takes  a  deep  inhalation  and 
during  this  act  raises  the  shoulders,  rolls  them 
backward  and  holds  the  breath  for  three  to  five 
seconds  while  in  this  position.  (See  Fig.  66.)  Then 
she  exhales  while  moving  the  shoulders  forward 
and  downward.  This  exercise  which  she  should 
take  frequently  every  day  she  should,  of  course, 
only  practice  in  pure  air,  preferably  near  the  open 
window  or  when  outdoors.  It  is  evident  that  not 
only  the  respiratory,  but  also  the  circulatory,  in 
fact  the  whole  system,  must  be  benefited  by  such 
a  practice  of  deep  breathing. 

The  living  and  the  sleeping  room  of  the  preg- 
nant woman  should  always  be  well  ventilated  and 
at  least  one  window  should  be  kept  open  in  the 
bedroom  even  in  cold  weather.  While  it  is  hard 
to  demonstrate  that  the  fear  so  many  people  have  of 
night  air  is  indirectly  responsible  for  a  good  deal 
of  tuberculosis,  I  nevertheless  believe  this  to  be 
the  case.  Some  people  will  sleep  in  a  small  bed- 
room, often  several  individuals  together,  with 
windows  tightly  closed,  breathing  the  same  air  over 
and  over  again,  and  thus  each  surely  poisoning 
himself  with  the  toxic  products  of  his  own  exhala- 
tion and  that  of  the  other  sleepers. 

The  newly  born  child  is  as  much  in  need  of  pure 


356  TUBERCULOSIS 

air  as  the  grown  up  person,  and  while  in  early  in- 
fant life  the  system  requires  more  warmth,  the  air 
the  child  is  to  breathe  must  be  free  from  dust  and 
other  impurities.  The  lying-in  room  and  nursery 
should  be  well  ventilated  and  their  temperature 
well  regulated.  The  atmosphere  in  such  rooms 
should  be  warm  enough,  but  never  be  too  hot  or 
too  dry. 

As  the  young  child  grows,  it  should  gradually  be- 
come accustomed  to  cooler  air.  The  habit  of  en- 
veloping the  child's  face  in  a  thick  veil  when  it  is 
taken  out  for  an  airing  is  absurd,  and  if  veiling  is 
used  at  all,  it  should  be  thin,  permitting  the  air  to 
have  access  to  the  face.  As  the  child  grows  up,  at- 
tention should  be  paid  to  its  breathing.  It  should 
be  noted  whether  it  breathes  through  the  nose  as 
it  should,  or  whether  the  nose  seems  obstructed 
and  it  breathes  with  its  mouth  open.  It  must  be 
remembered  that  mouth  breathing  in  children  is 
a  predisposing  cause  to  frequent  colds,  to  bron- 
chitis and  similar  affections,  all  of  which  in  many 
instances  must  be  considered  fore-runners  of  con- 
sumption. Mouth  breathing  in  children  is  caused, 
as  a  rule,  by  certain  growths  in  the  throat  (adenoid 
vegetation)  and  sometimes  by  enlarged  tonsils,  or 
by  polypi  in  the  nose.  Besides  its  deleterious  in- 
fluence on  the  child's  respiratory  system,  adenoid 
vegetation  may  also  result  in  difficulty  of  hearing, 


iPREVENTiON  OF  TUBERCULOSIS         357 

consequent  impairment  of  the  intellect,  and  even 
in  actual  deformities  of  the  jaw.  Adenoids  and 
all  other  obstructions  to  free  breathing  should  be 
promptly  removed  by  timely  operations. 

When  a  child,  because  of  its  delicate  constitution, 
is  susceptible  to  frequent  colds,  so  that  one  may 
hesitate  to  take  it  much  outdoors,  it  should  be 
borne  in  mind  that  fresh,  pure  air  really  does  not 
give  colds.  What  are  commonly  known  as  colds 
are  often  an  infectious  disease  due  to  a  specific 
microorganism  which  fastens  itself  more  readily 
on  a  delicate  system.  To  overcome  such  a  sus- 
ceptibility to  colds,  one  should  resort  to  the  ju- 
dicious use  of  cold  water. 

From  the  tenth  to  the  twelfth  month  one  should 
accustom  the  child  gradually  to  cold  baths.  The 
best  time  to  begin  is  after  its  daily  warm  bath. 
Rub  the  child  a  few  times  with  the  hands  dipped 
in  cold  water,  and  then  wipe  it  rapidly.  By  and 
by  one  may  begin  with  cold  sponging,  and  later 
with  a  little  douche.  In  the  use  of  cold  water  it  is 
absolutely  necessary  that  the  reaction  should  fol- 
low rapidly.  This  reaction,  as  is  well  known,  is 
manifested  by  a  pleasant  warmth  perceived  by  the 
child,  and  is  made  visible  externally  by  a  reddish 
appearance  of  the  skin.  Whenever  cold  water  is 
applied  to  the  skin,  one  will  notice  at  first  a  certain 
whiteness  or  pallor  which  is  caused  by  the  contrac- 


358  TUBERCULOSIS 

tion  of  the  external  blood  vessels.  The  return  of 
the  blood  to  the.  surface  causes  a  reddening  of  the 
skin.  Whenever  reaction  is  lacking  or  tardy,  the 
advice  of  the  physician  should  be  sought. 

Of  course,  it  goes  without  saying  that  a  child 
should  always  be  properly  dressed.  In  order  that 
its  lungs  may  develop  to  the  fullest  extent  it  must 
not  be  hindered  by  restricting  garments,  partic- 
ularly by  tight  neckwear,  collars,  or  bands.  Fur- 
thermore, it  must  be  remembered  that  to  dress  the 
neck  too  warmly  lessens  the  power  to  resist  taking 
cold  when  there  happens  to  be  a  change  in  the 
atmosphere.  The  less  one  is  accustomed  to  bundle 
up  the  neck,  the  more  freely  will  one  breathe  and 
the  less  will  one  be  likely  to  take  cold. 

When  a  girl  develops  into  a  young  woman,  one 
should  bear  in  mind  that  the  tightly  laced  corset 
is  one  of  the  most  injurious  garments  that  can  be 
worn.  Not  only  is  free  and  natural  breathing  in- 
terfered with  by  this  article  of  dress,  but  indi- 
gestion and  disturbances  in  the  circulation  follow 
excessively  tight  lacing.  Anaemia,  or  poverty  of 
blood,  so  often  observed  in  young  girls,  can  very 
frequently  be  ascribed  to  this  unnatural  mode  of 
dress  which  does  not  permit  either  a  free  circu- 
lation or  sufficient  oxygenation  of  the  blood. 

We  reproduce  here  three  pictures  to  better  illus- 
trate the  results  of  excessive  lacing.    Figure  107 


PREVENTION  OF  TUBERCULOSIS 


359 


Fig.  107.  Situation 
of  Vital  Organs  in 
a  Normal  Chest. 


Fig.  108.  Situation 
of  Vital  Organs  in 
Constricted  Chest. 


Fig.  109.  Skeleton 
of  Chest,  Perma- 
nently Constricted 
by  too  Tight  Lacing. 


shows  the  situation  of  the  organs  in  the  chest  and 
abdomen  in  a  normal  thorax.  Figure  108  shows 
lungs,  liver,  and  intestines  as  they  appear  in  a 
thorax  constricted  by  wearing  a  tightly  laced  corset 
for  a  number  of  years.  Figure  109  show^s  the  skele- 
ton of  a  chest  deformed  by  tight  lacing. 

In  the  preceding  chapters  we  have  spoken  of 
child  labor  in  factories  and  workshops,  and  of  too 
much  work  at  school;  but  there  is  another  way  in 
which  the  child's  constitution  may  be  injured  and 
for  which  the  parents  are  responsible.  I  refer  to 
child  labor  at  home.  Often,  thoughtlessly,  parents 
make  little  girls  in  their  teens  take  care  of  the 
smaller  brothers  and  sisters  and  force  them  to 
help  cook  and  to  wash,  and  I  know  of  families  in 
which  the  same  duties  are  imposed  upon  the  young 
boys  who,  in  addition,  have  to  do  all  the  errands  of 
the  family.  When  one  considers  that  these  chil- 
dren must  also  go  to  school,  one  can  fully  realize 


36o  TUBERCULOSIS 

how  dreary  their  httle  hves  must  be,  how  httle 
play  they  have,  and  how  their  health  must  become 
undermined  because  of  the  great  physical  strain 
which  is  put  on  their  growing  organisms  and  be- 
cause of  the  lack  of  healthful  outdoor  exercises. 
Particularly  pathetic  is  the  lot  of  little  "boys  and 
girls  between  the  ages  of  ten  and  fourteen  who, 
because  of  the  loss  of  one  parent,  father  or  mother, 
must  fill  the  vacant  place  while  the  remaining  par- 
ent is  absent  to  earn  a  living  for  the  family.  In 
such  instances  the  older  girl  or  boy  must  often  be 
the  servant  of  the  family.  I  have  seen  ''  little 
mothers  "  in  the  tenement  homes  whose  lives  were 
virtually  sacrificed,  they  having  developed  tuber- 
culosis because  of  the  physical  strain  put  upon 
them. 

It  does  not  require  much  for  the  tubercle  bacil- 
lus to  get  the  best  of  such  an  enfeebled  child's  or- 
ganism. Parents  should  bear  this  in  mind,  and 
everybody  who  can  help  to  prevent  such  conditions 
should  do  his  utmost  to  save  the  lives  of  the  little 
children. 

As  soon  as  the  intelligence  of  the  growing  child 
will  permit,  it  should  be  taught  to  breathe  deeply, 
and  later  on  be  taught  the  exercises  which  we  have 
described  in  full  in  Chapter  IX,  when  speaking  of 
prevention  of  tuberculosis  during  school  life. 

In  speaking  of  the  social  mission  of  the  3ana- 


PREVENTION  OF  TUBERCULOSIS    361 

torium,  we  have  mentioned  the  fact  that  alcohol- 
ism must  be  prevented  in  order  that  tuberculosis 
may  be  cured,  and  here  we  wish  to  say  that  the 
excessive  and  injudicious  use  of  alcoholic  drinks, 
particularly  whiskey  and  the  stronger  liquors,  is  a 
very  pronounced  predisposing  factor  to  tubercu- 
losis. I  am  of  the  opinion  that  as  long  as  there  is 
excess  and  intemperance  in  the  use  of  alcohol  as 
a  beverage,  so  long  v/ill  it  be  impossible  to  stamp 
out  tuberculosis. 

It  is  not  only  well  known  that  alcoholism  pre- 
disposes to  tuberculosis,  but  it  has  also  been  sta- 
tistically demonstrated  that  the  children  of  al- 
coholic parents  contract  tuberculosis  more  readily 
than  children  of  temperate  parents.  In  my  labors 
among  the  poor  I  have  often  sought  to  convince 
tuberculous  patients  of  the  folly  of  spending  money 
for  alcohol  as  a  means  to  cure  the  disease.  If  they 
would  spend  the  same  amount  of  money  for  nu- 
tritious food,  they  themselves  would  probably  have 
been  cured,  much  more  readily,  and  their  families 
could  have  lived  in  greater  comfort. 

There  are  sometimes  cases  of  consumption  in 
which  the  judicious  administration  of  alcohol  as  a 
medicine  is  indicated,  and  I  would  therefore  re- 
gret if  ever  a  law  should  be  enacted  which  would 
prevent  a  physician  from  prescribing  alcohol  in 
the  treatment  of  disease, 


362  TUBERCULOSIS 

Since  the  alcohol  problem  is  one  of  the  factors 
of  the  tuberculosis  problem,  I  feel  justified  in 
giving  a  few  suggestions  on  this  great  question. 
While  I  believe  that  excessive  use  of  alcohol  is  re- 
sponsible for  more  disease,  more  tuberculosis  in 
particular,  and  also  more  crime  than  any  other 
one  cause,  I  still  question  the  wisdom  of  absolute 
prohibition  in  our  present  state  of  civilization. 

Could  the  Gothenburg  system  be  carried  out  in 
the  United  States,  I  would  certainly  favor  it  as  a 
means  of  decreasing  intemperance,  and  conse- 
quently crime  and  disease.  This  system  consists 
in  the  manufacture  and  sale  of  alcohol  by  the  gov- 
ernment, and  giving  the  dispenser  of  alcohol  a 
salary,  so  that  no  benefit  shall  accrue  to  him  from 
the  amount  of  alcohol  he  sells.  The  law  strictly 
prohibits  the  sale  of  liquor  to  the  intoxicated,  the 
habitual  drunkard,  and  to  minors.  I  am  almost 
tempted  to  suggest  this  method  to  some  of  our 
prohibition  states — it  would  probably  tend  more 
to  decrease  intemperance  than  prohibition  laws  do 
now  as  they  have  worked  in  some  places.  How- 
ever, with  a  heterogeneous  population  like  ours, 
the  same  laws  are  perhaps  not  applicable  to  every 
state.  Prohibition  has  decreased  crime  in  the 
South  among  the  Negroes,  while,  if  I  am  correctly 
informed,  crime  and  arrests  for  intoxication  are 
on  the  increase  in  Maine. 


I^REVENTION  OF  TUBERCULOSIS  1,62, 

It  is  the  same  with  individual  states  as  it  is  with 
individual  men  and  women.  They  have  their 
idiosyncrasies,  peculiarities,  and  different  constitu- 
tions. Some  people  can  not  take  a  teaspoonful  of 
liquor  without  feeling  the  intoxicating  effect ;  others 
can  not  drink  the  smallest  quantity  without  a  de- 
sire being  aroused  for  more  than  is  good  for  them. 
It  must  be  self-evident  that  these  t}^es  of  people 
with  peculiar  constitutions  should  religiously  re- 
frain from  taking  alcoholic  drinks. 

That  a  low  type  of  saloon  is  injurious  to  any 
community  every  one  will  admit.  It  would  seem 
that  in  most  of  our  states  it  will  be  difficult  to  en- 
force strict  prohibition  laws.  To  create  by  a  higher 
license  a  higher  type  of  saloon  and  diminish  their 
numbers,  must  surely  have  a  good  effect. 

What  in  my  humble  opinion  is  injurious  to  the 
individual  as  well  as  to  society,  causing  many  a 
man  to  become  intemperate  is,  on  the  one  hand, 
the  American  treating  habit,  and  on  the  other,  the 
habit  of  taking  alcoholic  drinks  on  an  empty 
stomach  and  between  meals.  For  all  this  I  have 
but  one  remedy — education.  The  treating  habit, 
so  far  as  liquor  is  concerned,  must  be  abolished  by 
teaching  the  young  through  the  practice  and  ex- 
ample of  the  adults,  that  the  custom  is  wrong  and 
should  be  discountenanced. 

There  should  be  institutions  for  the  cure  of  the 


364  TUBERCULOSIS 

habitual  drunkard  to  which  he  may  go  himself  or 
be  committed  by  the  court,  if  his  conduct  is  such 
as  to  make  such  a  procedure  justifiable. 

There  are  few  men,  and,  perhaps,  not  one 
v.'oman  in  this  country  who  would  not  be  willing 
to  do  something  toward  the  decrease  of  alcoholism 
and  its  concomitant  social  misery.  If  well-meaning 
men  and  women  would  unite  in  their  efforts  to  sup- 
press the  treating  habit  by  practice  and  example, 
and  would  pledge  themselves  never  to  partake  of 
alcohol  except  in  moderate  quantities  with  their 
meals  and  in  diluted  form,  I  am  convinced  that  a 
greater  step  toward  temperance  would  be  made 
than  by  any  other  means  heretofore  employed. 

Aside  from  this,  I  believe  that  the  building  of 
model  tenement  houses  by  private  or  municipal 
enterprise,  the  creation  of  more  parks  and  play- 
grounds and  healthful  places  of  amusement  open 
Sundays  and  week-days,  where  the  laborer  can  par- 
take of  non-alcoholic  drinks  and  enjoy  the  society 
of  his  friends,  will  do  more  to  do  away  with  alco- 
holism than  many  a  more  strict  measure. 

In  short,  let  us  not  forget  that  to  combat  al- 
coholism we  must  combat  social  conditions  creat- 
ing misery  and  want.  If  there  was  more  social 
justice,  we  would  need  to  have  fewer  charitable 
institutions.  While  it  is  true  that  alcoholism  be- 
gets crime,  misery,  and  unhappiness,  it  is  equally 


PREVENTION  OF  TUBERCULOSIS  365 

true  that  much  misery  and  suffering  begets  al- 
cohoHsm.  In  a  civihzed  country  like  ours  there 
should  never  be  such  a  condition  as  a  man  willing 
to  labor,  but  obliged  to  suffer  misery  and  want 
for  want  of  labor. 

There  is,  indeed,  a  great  opportunity  in  this 
respect  for  practical  statesmanship  and  practical 
philanthropy.  I  am  convinced  that  in  a  com- 
munity which  provides  labor  and  just  pay  for  all 
those  willing  to  labor,  there  will  be  need  of  fewer 
pohce,  fewer  prisons,  penal  institutions,  and  in- 
sane asylums,  while  the  commonwealth  will,  in 
the  end,  gain  in  all  respects  morally,  sanitarily, 
and  financially. 

Where  it  is  feasible  for  laborers  working  in  the 
open,  and  also  for  those  working  indoors,  cool,  non- 
alcoholic drinks  should  be  dispensed  in  summer 
and  warm  ones  in  winter,  at  reasonable  rates. 

Lastly,  I  would  suggest  that  well-kept  comfort 
stations  should  be  more  numerous  throughout  our 
large  cities  than  they  are  at  the  present  time.  A 
municipality  which  will  do  its  duty  in  this  respect 
will  prevent  the  necessity  of  men  going  into  saloons 
for  calls  of  nature,  and  then  feeling  called  upon  or 
being  tempted  to  spend  money  there  for  drink. 

We  have  already  referred  to  the  proper  housing 
of  the  masses,  and  would  emphasize  here  that  un- 
sanitary housing  and  lack  of  sunlight  and  air  in 


v) 


66  TUBERCULOSIS 


the  home  must  be  considered  a  strong  predispos- 
ing factor  to  disease.  It  brings  about  the  acquired 
t\^e  of  predisposition  to  tuberculosis.  While  the 
individual  laborer  and  employee  may  not  always 
be  able  to  procure  the  necessary  ventilation  he 
would  wish  to  have  while  at  work,  he  ought 
to  be  able  to  have  it  at  his  home.  He  should 
practice  and  teach  his  family  the  love  of  fresh  air, 
deep  breathing,  and  particularly  keeping  the  bed- 
room windows  open  at  night.  During  the  warmer 
seasons,  outdoor  eating,  outdoor  concerts,  out- 
door theatres,  etc.,  should  be  encouraged.  We 
can  learn  much  in  this  respect  from  European 
cities. 

In  the  preceding  chapters  we  have  spoken  of 
the  value  of  cooking-schools  for  children  and 
adults,  and  also  of  the  value  of  housekeeping  cen- 
ters. It  is  a  well-known  fact  that  there  is  a  great 
deal  of  waste  of  food  substances  in  the  homes  of 
the  poor  because  of  ignorance,  and  much  of  the 
bad  feeding  and  underfeeding  of  the  masses  is  due 
to  lack  of  knowledge.  It  can  not  be  urged  strongly 
enough  upon  married  women  and  girls,  the  future 
mothers  of  the  nation,  to  avail  themselves  of  all 
possible  opportunities  to  learn  practical,  economic, 
and  healthful  cooking,  and  practical  and  sanitary 
housekeeping. 

People  in  general  should  embrace  all  opportuni- 


PREVENTION  OF  TUBERCULOSIS  367 

ties  to  learn  what  they  can  about  the  prevention 
of  disease.  They  themselves  should  practice  all 
they  know  concerning  these  important  matters; 
lead  sober,  regular  lives;  be  temperate  in  all 
things.  They  should  practice  clean  living,  plain 
cooking,  and  clean  housekeeping,  the  utilization  of 
fresh  air  and  sunlight.  Everybody  should  make 
it  his  rule,  whether  tuberculous  or  not,  never  to 
expectorate  when  indoors  except  in  a  proper  re- 
ceptacle (spittoon  or  cloth);  and  when  outdoors, 
if  he  must  spit,  to  spit  into  the  gutter  but  never  on 
the  sidewalk. 

In  cases  where  prohibitions  against  expectora- 
tion are  posted,  or  other  health  notices,  the  pub- 
lic should  take  particular  pains  to  heed  them  and 
not  act  in  a  spirit  of  opposition.  When  an  em- 
ployer is  trying  to  do  his  best  to  look  out  for  the 
sanitary  condition  of  his  employees,  they  should 
cooperate  with  him  in  every  way  possible  in  order 
to  reduce  the  sources  of  infection  or  causes  of 
predisposition. 

The  public  should  attend  the  popular  lectures 
on  health  and  sanitation,  not  neglecting  those  on 
the  prevention  of  tuberculosis.  They  should  re- 
member that  the  knowledge  thus  gained  is  power 
and  will  help  in  preventing  disease,  misery,  and 
death.  Every  individual,  in  no  matter  what  walk 
of  life,  can  help  to  prevent  tuberculosis,  and  to  do 


36S  TUBERCULOSIS 

this  means  happiness  for  others  and  happiness  for 
himself. 

When  speaking  of  the  care  to  be  taken  in  the 
disposal  of  sputum  (Chapter  I),  we  mentioned 
how  the  housefly  can  become  a  conveyor  of  infec- 
tion. It  can  spread  tuberculosis  and  other  dis- 
eases. How^  easily  can  nearly  every  one  help  in 
the  extermination  of  this  insect! 

It  should  be  the  duty  of  every  one  to  remember 
this  and  do  what  he  can  to  prevent  this  source 
of  infection.  Every  fly  in  the  sick  room,  no  mat- 
ter of  what  disease  a  patient  may  suffer,  should 
be  killed.  Since  the  fly  breeds  in  manure  in  pref- 
erence to  all  other  places,  we  must  concentrate 
our  attention  to  the  destruction  of  this  insect  in 
its  early  stages.  To  this  end  all  vaults  and  pits 
containing  stable  manure  should  be  screened  or 
sprinkled  with  lime  or  kerosene.  All  garbage, 
vegetable  matter,  or  other  decaying  material 
tending  to  attract  flies  should  be  covered.  Some 
municipal  ordinance  concerning  stable  hygiene 
with  a  view  of  preventing  the  breeding  of  flies 
and  the  screening  of  all  articles  of  food  exposed 
for  sale,  would  be  most  timely.  However,  the 
individual  also  must  do  his  duty  by  screening 
windows  and  doors,  especially  those  of  the  kitchen 
and  dining  room,  and  the  covering  of  all  food 
suVjstances. 


PREVENTION  OF  TUBERCULOSIS         369 

Another  method  whereby  every  individual,  no 
matter  in  what  station  of  hfe,  can  be  helpful  in 
preventing  tuberculosis  in  himself,  his  friends  and 
neighbors,  is  by  his  example  of  love  for  fresh  air. 
We  have  spoken  of  this  a  number  of  times  in  refer- 
ence to  the  cure  as  well  as  to  the  prevention  of 
tuberculosis,  but  it  can  hardly  be  emphasized  too 
much.  If  one  can  not  sleep  in  the  open  air,  he  can 
certainly  have  his  window  open  at  night.  If  his 
occupation  demands  a  great  deal  of  indoor  life,  or 
perhaps  makes  inhalation  of  dust  unavoidable,  he 
should  be  all  the  more  eager  to  spend  his  leisure 
hours  in  the  fresh  air,  to  breathe  deeply  often  when 
in  pure  air,  to  avoid  places  of  amusement  where 
the  air  is  impure,  smoky,  and  dusty,  and  to  keep 
regular  hours,  and  be  moderate  and  temperate  in 
all  things.  He  will  thus  be  doing  all  he  can  to 
counteract  whatever  bad  effect  his  occupation  may 
have  on  his  health. 

It  is  not  only  in  the  prevention  of  tuberculosis 
that  any  individual  may  be  able  to  help  by  spread- 
ing the  knowledge  he  may  have,  through  the  prac- 
tice of  it  or  by  imparting  it  to  his  neighbor  or 
friend  in  a  tactful  manner  where  it  is  most  needed, 
that  is  to  say,  to  an  untrained  consumptive;  but 
every  well  meaning  citizen,  young  or  old,  even  in 
the  most  moderate  circumstances,  will  also  have 
opportunity  to  help  in  the  cure  of  tuberculosis. 


370  TUBERCULOSIS 

There  is  an  excellent  movement  now  on  foot 
known  as  the  Red  Cross  anti-tuberculosis  work. 
The  American  National  Red 
Cross  issued  last  year,  before 
Christmas,  a  beautiful  stamp 
which  bore  a  wreath  of  holly  with 
the  words  "Merry  Christmas" 
and  ''Happy  New  Year."  (Fig. 
no.)    The  stamps  were  sold  in 

Fig.  iio.    American      i        .     ti  t  .  j 

J.  ,  n       c.        sheets  like  an  ordmary  stamp  and 

Red  Cross  Stamp  «'  ^ 

for  the  Year  1908.  also  in  Small  books  (nine  for  ten 
(Original  Printed  ^^^^^  twcnty-four  for  twcnty-five 

in  Red.)  '  \  ^ 

cents,  forty-eight  for  fifty  cents), 
like  the  Government  postage  stamps.  The  Christ- 
mas stamp  was  not  good  for  postage.  It  did  not 
carry  any  kind  of  mail,  but  any  kind  of  mail 
carried  it.  Some  eleven  million  stamps  were  sold 
in  the  United  States,  which  means  that  more  than 
$100,000  were  contributed  to  the  Red  Cross  anti- 
tuberculosis work  throughout  the  country  during 
Christmas  tide  of  1908.  The  New  York  County 
branch  alone  netted  $11,000,  and  one  of  the  imme- 
diate results  of  this  gratifying  help  from  the  people 
of  the  City  of  New  York  was  the  establishment  of 
the  Red  Cross  Tuberculosis  Camp  on  the  roof  of 
the  Vanderbilt  Clinic  of  which  we  gave  an  illustra- 
tion.     (Fig.  99.) 

In  the  preceding  chapter  we  have  spoken  of  the 


PREVENTION  OF  TUBERCULOSIS         371 

activities  of  the  Tuberculosis  Committee  of  the 
City  of  New  York.  While,  of  course,  it  can  not  be 
expected  that  such  a  vast  activity  can  be  carried 
out  by  every  committee,  much  useful  work  can 
be  done  even  on  a  smaller  scale,  and  such  com- 
mittees should  always  be  composed  not  only  of 
physicians  but  also  of  laymen.  Here  again  is  an 
opportunity  for  helpfulness  by  the  layman  who 
is  willing.  By  becoming  a  member  of  such  a 
committee  or  a  member  of  an  association  for  the 
study  and  prevention  of  tuberculosis,  he  can  show 
his  interest  and  participate  in  the  crusade  against 
tuberculosis.  Labor  organizations,  trades  un- 
ions, workingmen's  mutual  relief  societies,  etc., 
should  make  it  a  point  to  have  all  their  members 
educated  in  the  prevention  of  tuberculosis,  and  no 
such  organizations  should  exist  without  its  com- 
mittee on  tuberculosis.  Life  insurance  companies 
can  also  be  helpful  by  distributing  anti-tubercu- 
losis literature  among  their  policy  holders,  and 
thus  help  in  the  general  campaign  education.  A 
good  example  in  this  respect  was  recently  given 
by  the  Metropolitan  Life  Insurance  Company 
through  its  Industrial  Department  at  New  York 
under  the  management  of  Dr.  Lee  K.  Frankel. 

No  fair-sized  community  should  be  without  its 
anti-tuberculosis  association  or  committee.  Of  the 
steady  growth  in  number  and  strength  of  such 


372  TUBERCULOSIS 

associations,  the  following  statistics  are  the  best 
evidence. 

About  four  years  ago,  in  February,  I  made  a  care- 
ful inquiry  concerning  existing  anti-tuberculosis 
committees  and  associations  in  the  United  States, 
and  I  could  then  only  count  forty-nine  anti- 
tuberculosis bodies  calling  themselves  associations, 
societies,  committees,  or  leagues.  In  May,  1905, 
in  Washington,  there  was  held  the  first  meeting  of 
the  National  Association  for  the  Study  and  Pre- 
vention of  Tuberculosis  under  the  presidency  of 
Dr.  Edward  L.  Trudeau.  Dr.  William  Osier,  now 
of  Oxford,  and  Dr.  Hermann  M.  Biggs,  of  New 
York,  were  the  vice-presidents.  Dr.  Henry  Barton 
Jacobs  was  the  Secretary,  and  Surgeon-General 
George  ]\I.  Sternberg,  the  Treasurer.  Soon  after 
this,  an  Executive  Secretary  in  the  person  of  Pro- 
fessor Livingston  Farrand  was  appointed,  and  it  is 
largely  owing  to  his  energy  that  at  the  end  of  1906 
there  existed  as  many  as  sixty-tw^o  anti-tuberculosis 
associations.  The  year  1907  added  forty-nine,  and, 
at  the  time  of  writing  the  closing  chapter  of  this 
book  (March  15,  1909),  there  was  a  total  of  273 
anti-tuberculosis  associations  in  the  United  States. 

As  has  Ijcen  already  stated,  these  associations 
are  composed  of  lay  and  medical  men  and  women. 
This  speaks  well  for  the  growing  interest  in  the 
anti-tuberculosis  cause.     The  present  membership 


PREVENTION  OF  TUBERCULOSIS 


373 


Fig.    III.     Proposed  Quarters  of  National  Pythian  Sanatorium,  Las 
Vegas,  N.  M.      1300  Acres  Have  Been  Donated  to  this  Institution. 

of  the  National  Association  is  about  i,6oo.    Much 
is  done,  but  there  is  more  to  do. 

For  masonic  and  other  fraternal  societies,  also 
for  mutual  benefit  associations  of  all  kinds,  the 
solution  of  the  tuberculosis  problem  offers  an 
unusual  field  for  most  humane  activities ;  and  it  is 
encouraging  to  note  the  progress  being  made  in 
this  direction.  The  Grand  Lodge  of  Free  and 
Accepted  Masons  of  the  State  of  New  York  has 
already  collected  a  good-sized  fund  and  owns  a 
tract  of  land  on  which  it  expects  to  build  a  tuber- 
culosis sanatorium.  The  Knights  of  Pythias 
fraternity  has  a  National  Pythian  Sanatorium  of 
which  they  expect  to  make  a  model  institution. 
It  is  located  at  Las  Vegas,  N.  M.     (Fig.  iii.) 


374 


TUBERCULOSIS 


Fig.  112.     Union  Printers'    Home  for   Consumptives.     Established 
and  Maintained  by  the  International  Typographical  Union. 

The  Modern  Woodmen  have  a  sanatorium  for 
their  tuberculous  members  at  Colorado  Springs, 
and  in  the  same  place  the  Union  Printers  have  a 
beautiful  consumptives'  home  for  their  afflicted 
brethren,  which  has  been  erected  and  is  main- 
tained by  the  International  Typographical  Union. 
In  its  prospectus  it  very  appropriately  says:  ''Its 
bounty  is  unpurchasable ;  its  charity  without 
price."  (Fig.  112.)  At  the  recent  meeting  of  the 
Supreme  Council  of  the  Royal  Arcanum,  resolu- 
tions urging  the  establishment  of  a  tuberculosis 
sanatorium   by   that   order   were   presented   and 


376  TUBERCULOSIS 

passed.  At  Black  Mountain,  N.  C,  there  has 
existed  for  a  number  of  years  a  sanatorium  es- 
tablished by  the  Royal  League. 

There  is  one  more  very  important  field  of  in- 
terest to  the  populace  at  large  in  the  direction  of 
prevention  as  well  as  of  the  cure  of  tuberculosis. 
I  refer  to  what  might  be  accomplished  in  the 
United  States  by  insurance  against  tuberculosis. 
This  has  been  done  in  other  countries,  especially 
in  Germany,  with  unqualified  success.  In  the 
latter  country  insurance  is  obligatory  against  ac- 
cident, old  age,  and  disease  for  all  laborers  and 
employees  not  earning  enough  wages  to  provide, 
under  ordinary  circumstances,  for  any  of  the  three 
mentioned  emergencies.  The  beneficial  results  of 
such  an  insurance  in  reducing  the  morbidity 
(number  of  sick)  and  mortality  from  tuberculosis 
must  be  evident  when  one  considers  the  following 
points.  At  the  slightest  indisposition  or  other 
apprehension  of  developing  tuberculosis,  the  policy 
holder  may  apply  for  examination  at  the  office 
of  some  of  the  insurance  company's  physicians. 
Thus,  an  early  diagnosis,  if  tuberculosis  is  present, 
is  assured.  The  insurance  companies  in  Germany 
soon  learned  that  when  one  of  their  policy  holders 
was  afflicted  with  early  tuberculosis,  it  would  be 
to  their  financial  advantage  to  immediately  in- 
stitute the  best  possible  treatment  for  such  an  in- 


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378  TUBERCULOSIS 

dividual,  which  was  for  the  majority  of  this  class  of 
cases — the  sanatorium  treatment.  They  made  ar- 
rangements with  private  sanatoria  (Fig.  113)  for  im- 
mediate reception  of  their  patients  who  being  in  the 
earlier  stages  were,  of  course,  much  sooner  cured 
than  had  they  been  allowed  to  go  on  until  the  disease 
had  reached  a  more  advanced  and  less  curable  stage. 

In  time,  these  insurance  companies  found  out 
that  it  would  pay  them  to  own  and  maintain  san- 
atoria themselves.  The  result  is  that  there  exist 
now  in  Germany  a  number  of  this  kind  of  sana- 
toria owned  by  insurance  companies,  and  in  flour- 
ishing condition.  (Fig.  114.)  While  on  the  surface 
these  companies  have  entered  into  this  sanatorium 
building  and  managing  as  a  business  proposition, 
it  must,  nevertheless,  be  acknowledged  that  such 
enterprises  have  a  very  large  humanitarian  aspect, 
for  many  valuable  lives  are  thus  saved  and  a  great 
deal  of  sorrow  and  misery  spared  to  the  masses. 

It  is  for  this  reason  that  I  most  heartily  recom- 
mend to  our  life  insurance  companies  to  imitate 
the  German  insurance  against  accident,  old  age, 
and  disease,  and  not  to  exclude  early  cases  of  tuber- 
culosis, nor  predisposed  individuals  from  becom- 
ing policy  holders.  I  also  recommend  the  build- 
ing of  their  own  sanatoria  for  employees  and  policy 
holders,  as  contemplated  by  the  Metropolitan  Life 
Insurance  Company. 


CHAPTER  XII 

PROSPECT     OF     THE     ULTI^IATE     ERADICATION     OF 
TUBERCULOSIS 

One  of  the  greatest  scientists  of  the  nineteenth 
century,  a  man  who  through  his  studies  and  the  dis- 
coveries which  he  gave  to  the  world,  has,  perhaps, 
done  more  to  save  human  beings  than  any  other 
man,  was  Louis  Pasteur  of  France.  (Fig.  115.) 
Among  his  writings  one  can  find  two  sentences 
which  to  my  mind  are  well  fitted  to  inspire  man- 
kind, that  is  to  say,  every  one,  rich  and  poor,  young 
and  old,  the  statesman  and  the  ordinary  citizen,  the 
physician  and  the  tuberculous  patient,  to  do  all 
he  can  to  be  helpful  in  this  world  crusade  against 
tuberculosis.  The  first  of  these  inspiring  sentences 
reads,  "II  est  au  pouvoir  de  I'homme  de  faire  dis- 
paraitre  toutes  les  maladies  parasitaires "  (It  is  in 
the  power  of  man  to  cause  all  parasitic  diseases  to 
disappear  from  the  world). 

The  bacillus  of  tuberculosis  is  a  parasite — it  need 
not  exist.  Outside  of  the  animal  organism  it  re- 
tains its  virulence  in  darkness  and  filth,  and  in  the 
human  body  it  thrives  when  health  is  undermined 

379 


H*   <*>>-     #•*•    ^'^     0'»    Ck     Y7»*»««'>*    i«»#^\"* 

Fig.  115.      Louis  Pasteur  in  His  Laboratory. 


ULTIMATE  ERADICATION  381 

by  misery,  want,  ignorance,  or  excesses.  Through 
the  education  of  young  and  old  in  the  prevention 
of  tuberculosis  and  in  sanitation  in  general,  filth, 
darkness,  and  ignorance,  as  causes  of  tuberculosis 
among  the  masses,  will  be  removed.  To  convince 
employers  of  men  and  women  that  to  guard  the 
toilers  against  disease  will  be  of  mutual  benefit, 
and  to  teach  employees  to  share  in  the  work,  will 
cause  tuberculosis  as  a  disease  of  the  masses  to 
disappear  among  the  laboring  population.  States- 
men and  city  fathers  will  learn  that  to  take  care 
of  the  consumptive  poor  at  the  right  time  and  at 
the  right  place  tends  to  the  moral,  financial,  and 
sanitary  gain  of  every  community;  and  then  they 
will  not  hesitate  to  establish  sanatoria  and  special 
hospitals  for  the  cure  of  all  those  in  need  of  in- 
stitutional treatment.  By  the  enactment  of  wise 
and  humane  laws  they  will  diminish  social  misery, 
suffering,  and  want. 

The  second  of  the  two  immortal  phrases  of  the 
great  Pasteur  above  referred  to  reads,  ''En  fait  du 
bien  a  repandre,  le  devoir  ne  cesse  que  la  oii  le 
pouvoir  manque,"  which  might  be  interpreted  into 
English  as  follows:  "Our  duty  to  do  good  only 
ends  where  our  power  to  do  good  fails." 

If  the  lover  of  his  kind,  the  rich  philanthropist, 
would  follow  this  precept,  do  good  and  spread 
the  good,  help  to  build  model  tenements,  open  air 


382  TUBERCULOSIS 

schools,  preventoria  for  the  prevention,  and  san- 
atoria for  the  cure  of  patients,  and  provide  health- 
ful recreations  for  the  poor;  and  if  the  lover  of  his 
kind,  the  poor  philanthropist,  rich  in  heart  but 
poor  in  worldly  goods,  would  bring  his  knowledge, 
his  good  will,  his  labor,  and  his  mite  towards  the 
prevention  of  this  as  yet  the  most  prevalent  and 
fatal  of  all  diseases,  the  ultimate  eradication  of 
tuberculosis  would  seem  to  be  in  sight. 

It  is  not  safe  to  make  a  prophecy  as  to  when  this 
time  will  come,  but  it  may  safely  be  said  that 
w^hatever  we  do  in  the  direction  of  preventing  the 
development  of  tuberculosis,  will  prevent  social 
misery  and  social  ills.  Inasmuch  as  we  diminish 
tuberculosis  among  the  masses,  we  will  diminish 
suffering,  misery,  and  social  discontent;  and  when 
the  problem  of  tuberculosis  will  have  been  solved, 
this  disease  so  graphically  described  as  ''the  great 
white  plague"  forever  eradicated,  then  will  we  be 
nearer  the  millennium  than  we  have  ever  been  be- 
fore, and  Peace,  Health,  and  Happiness  will  be  our 
lot  on  earth. 


INDEX 

PAGE 
Adaptation  of  Sanatorium  Methods  at  Home  .  .  .  -57 
Adirondack  Cottage  Sanatorium  .  .314,  316,  317,  318,  $33 
Aerarium,  Bull's         .  .         .         .         .         .         .         .  -75 

Aerotherapy 57,     80 

Agnes  Memorial  Sanatorium       .         .         .  .         .         .  319,  320 

Air  in  its  Relation  to  Tuberculosis    .         .         .  .84,  356,  369 

Alabama  State  Sanatorium         .......  196 

Alcoholism 329,  361 

Almhouses  ..........  157 

Alphabet  in  Tuberculosis    ........  265 

Antagonism,  Unjustified      ........   283 

Anti-spitting  Ordinances     ....  133,   165,   218,  367 

Anti  tuberculosis  Associations  in  the  United  States    .         .         -372 
Atmosphere,  Pollution  of    ......         .     84,  131 

Bacillus  of  Tuberculosis      .         .         .     4,  5,  17,  164,  285,  296,  379 

Baker,    Dr.    Josephine         ........  283 

Barlow's  Sanatorium            ........  322 

Barnes,  Dr.  H.  L 193 

Baths 12,  53,  248 

Bed  Linen,  Care  of     .         .         .         .         .         .         .         .         .20 

Beds,  Klondike 77j  78 

Bement,  Mr.,  Chicago,  111. 127 

Bensel,  Dr.  Walter 283 

Berck-sur-Mer,   School  Sanatorium  and  Hospital                .         .  277 

Biggs,  Professor  Hermann  M.     .         .         .         -23,   133,   139,  372 

Billings,  Dr.  John  S.,  Jr.    .         .         .         .         .         .          .         .  149 

Bird,  Mr.,  Chicago,  111 127 

Bishop  of  Fano    ..........  285 

Bonney,  Dr.  S.  G 23 

Boston  Association  for  the  Relief  and  Control  of  Tuberculosis     .  336 

Bovine  Tuberculosis   .         .         .         .         .         ,         .         .216,  239 

Bowditch,  Dr.  Vincent  Y 24 

Brannan,  Dr.  John  W 273 

3^3 


384 


INDEX 


Breathing  Exercises 

Bull,  Dr.  T.  M. 

Busse,  Mayor  of  Chicago    . 

Carnegie,  Mr.  Andrew 

Carolina  Rest  for  Education  of  Mothers 

Chalice,  Hygienic 

Childlabor 

Childlabor  at  Home    . 

Children's  Sanatoria    . 

Children,  Tuberculosis  in  . 

Charity  Organizations,  Duties  of 

Church  Hygiene 

Circumcision,  Ritual  . 

Cities,  Buildings  of 

City  Employees,  Examination  of 

Class  Methods    . 

Cleaning  of  Rooms 


3i»  33,  43 


171 


Work  of 


Cleaning  of  Streets 

Clergy,  Duties  of 

Climate        .... 

Climatolog}',  Maxims  in 
Clinic  for  Tuberculosis 
Colds  .... 

Cold  Water 

Committee,  N.  Y.  Tuberculosis, 

Communion  Cup,   Hygienic 

Communion  Cup,  Individual 

Conclusions 

Concrete,  Reinforced,  for  Sanitary  Home 

Confessional  Chairs  and  Grates 

Connecticut  State  Sanatorium     . 

Cooking,  Instruction  in       .         .         . 

Cooperation  of  Federal,  State,  and  Municipal  Authorities 

Cough  ...... 

Country  Sanatorium  at  Otisville,  N.  Y 
Cremation  ..... 

Cronin,  Dr.  John  J.     . 


18 


157 


300. 


PAGE 

252,  354 

•  74 
.  127 

.  312 

.  281 

.  288 

.  212 

•  359 
.  276 

276,  354 
.  284 
.  284 
.  28s 
.  88 
.  165 

344,  349 
.  21 
.  132 
.  284 

172,  316 

•  33 
149,  153 

•  357 
53,  357 

•  306 
.  288 
.  286 
.  382 

•  125 
.  285 

196,  325 

.  280 

.  171 

I,  22,  50 

.  160 

•  295 
.  283 


INDEX 


38s 


PAGE 


Curability  . 

14 

.     30 

Gushing,  Mr.   Geo.  H. 

128 

Guspidors 

.      6 

7 

Darlington,  Commissioner  Thomas     , 

139 

167 

Davosplatz,  Switzerland 

339 

Day  Camps 

334 

Dedication 

2 

Despergnes 

295 

Dettweiler,    Geheimrath  P 

28 

33^ 

Devine,  Professor  Edw.  T 

350 

Diet  Kitchen 

3" 

Disinfection 

.     45, 

159 

220 

Dispensaries 

.  148, 

151 

156 

District  of  Columbia,  Sanatorium  of    . 

179 

Dixon,  Commissioner  Samuel  G. 

192 

Domestic  Animals,  Tuberculosis  in     . 

•         •         . 

244 

Douches 

82, 

357 

Dress.          .... 

13. 

49 

Dress  for  Predisposed  Children 

358 

Droplet  Infection 

5,  10,  20,  203 

231, 

342 

Dryness  of  Air  in  Homes     . 

121 

Dublin  Tuberculosis  Exhibition 

146 

Dust 

5,  17,  122, 

131 

238 

Duties  of  Those  Living  with  Patients 

16 

135 

Edison,  Mr.  Thomas  A.      . 

125 

Education,  Anti-tuberculosis 

.  146,  166 

232 

280 

Educators,  Duties  of    . 

246 

Edward  Sanatorium    .... 

324 

Elevated  Spittoons,  Self-flushing 

8,  9 

132 

Elliott,  Dr.  J.  H 

327 

Emmanuel  Church  Class  Patient 

302 

Emmanuel  Movement  and  Tuberculosis 

299 

Employees,  Examination  of 

232 

Employers,  Duties  of           ... 

228 

Eradication,  Prospect  of     . 

379 

Evans,  Commissioner  W.  '. 

E. 

167 

386 


INDEX 


Evening  Lectures  to  Adults  in  Public  Schools 

Examination  for  Tuberculosis 

Exercises  for  Patients 

Exercises  for  Prisoners 

Exhibition  .... 

Expectoration 

Expenses  and  Maintenance 

Factories   and   Tuberculosis 

Falkenstein  Sanatorium,  Germany 

Farmers'  Duties  in  Prevention  of  Tuberculosis 

Farming  Made  Attractive    .... 

Farrand,  Professor  Livingston    . 

Federal  Authorities,  Duties  of     . 

Federal  Department  of  Health    . 

Federal  Sanatorium  at  Fort  Bayard,  N.  M. 

Federal  Sanatorium  at  Fort  Stanton,  N.  M. 

Federal  Sanatorium  at  New  Fort  Lyon,  Colo. 

Financial  Gain  from  Timely  Treatment 

Fisher,  Dr.  E.  D 

Flies  and  Tuberculosis 

Folks,  Hon.  Homer     .... 

Food  and  Tuberculosis 

Forestry  Schools 

Fowler,  Dr. 

Frankel,   Professor  B. 

Frankel,  Dr.  Lee  K. 

Fraternal  Sanatoria 

Free  State  Hospital  at  Ray  Brook,  N.  Y. 

Funerals,  Cost  of        ...         . 

Galtier,    Dr 

Garden  City  Association  of  America    . 
Garden  City  Association  of  Great  Britain 
Gartner,  Dr.        ..... 

Gaylord  Farm  Sanatorium 

Goler,  Dr.  Geo.  W.,  Health  OlTicer     . 

Gothenburg  System    .... 


PAGE 

.  279 

i57»  iqSj  231,  269 

.  49 

.  208 

143,  144,  145 

5,  201,  367 

.  161 

215,  228 
340 
238 
226 

372 
171 
227 
217 
217 
217 
161 
24 

9,  ID,  368 

52,  169 
226 
211 
206 
371 

373 
310 
296 

295 
93 
94 
295 
325 
167 

362 


INDEX 


387 


Grancher,  Professor  J.  J. 
Greene,  Mr.  Frederick  D. 
Guilfoy,  Dr.  W.  H.     . 


134, 


Half-tent,  Knopf's       .... 
Handicapped,  Employment  for  the     . 
Handkerchiefs     ..... 
Health  Department's  Work 
Heating       ........ 

Height  of  Buildings 

Hereditary  Tuberculosis      ..... 

History  of  Patients  After  Having  Left  Sanatorium 
Holmes,  Rev.  John  H.       .         .         .         .         . 

Home  Sickness    ....... 

Home  Treatment         ...... 

Horses,  Tuberculosis  in      ....  . 

Hopital  pour  les  Enfayits  Tubercnleux  a  Berck-sicr-Mer 
Hospitals    ........ 

Housekeeping  Centers  ..... 

Houses,    Construction  of    .         .         .         .         -9 

Housing  Laboring  Population    .... 

Huggard,  Dr.      . 

Humidifier   ........ 

Hydrotherapy    .  ...... 

Hygiene,  Factory        ....... 

Hygiene,  Personal 

Hygrometer         ........ 

Indiana  State  Sanatorium  ...... 

Indoor  Occupations,  Number  of  People  Employed  in 

Infant,  Newborn,  Care  of    . 

Infection  by  Close  Contact         .... 

Infection  by  Ingestion         ...... 

Infection  by  Inhalation       ...... 

Infection  by  Inoculation     ...... 

Information  for  All     ....... 

Inland  Sanatorium  of  N.  Y.  Orthopaedic  Hospital 
Insane  Asylum  and  Tuberculosis       .         .  .         . 

Instruction  Leaflets 30,  47) 


PAGE 

28 
103 
297 


8,  9,  II 
160,  166 

119 


276 
156 


95,  107 
85>  92 


53 


134,  139 


58 

311 

20 
168 
230 

91 
353 
178 
288 

31 

301 

243 
277 

158 
282 
116 

365 

85 
122 

81 
228 

12 
123 

196 
90 

357 
169 

5 
5 
6 

54 
159 
197 
218 


388 


INDEX 


Insurance  Against  Tuberculosis  . 
International  Tuberculosis  Exhibit 
Iowa  State  Sanatorium 

Jacobi,  Professor  A.    . 
Jacobs,  Dr.  Henry  Barton   . 
Janeway,  Professor  Edw.  G. 
Janeway,  Professor  Theodore  C. 
Jewish  Hospital,  National    . 
Justice  to  Consumptives 

Kelly,  Mrs.  Florence    . 
Kentucky  State  Sanatorium 
King,  Dr.  Herbert  M. 
Kissing  Animal  Pets    . 
Kissing  Articles  of  Adoration 
Kissing,  Infection  through 
Kissing  the  Bible 
Klebs,  Dr.  Arnold  C. 
Knopf's  Cuspidors 
Koch  Institute    .... 
Koch,  Professor  Robert 
Krankenheim,  Weicker's     . 
Krauskopf,  Rev.  Joseph,  D.  D.    . 

Lacing,  Tight      .... 

Laryngeal  Tuberculosis 

Lectures      ..... 

Lectures  to  Employees 

Leipziger,  Dr.  Henry  M. 

Life  in  Fresh  Air 

Life  Insurance  Companies  Helpful  in 

Linen,  Care  of    . 

Littlejohn,  Professor  Harvey 

Ljunggren,  Rev.  C.   J.       . 

Locke,  Dr.  Edwin  A.    . 

Lodge,  Sir  Oliver 

Lodging  Houses  and  Tuberculosis 

London  Open  Air  School    . 


Propaganda 


P.\GE 

•  376 
.  144 
.  180 

24,  128 

•  372 

24,     27 

•  311 

•  293 

•  23 

.  282 
.  196 

•  330 

•  244 
.  284 

244,  267 
.  284 

•  24 

7,  9,  132 
.  312 

241,  350 

•  375 
.  288 

•  358 

.     36 

35i>  367 
.  232 

•  279 

•  369 

•  371 
,  20 
.  128 
.  287 
.  278 
.  129 
.  117 
.  270 


INDEX 


3^9 


Loomis  Sanatorium     . 

Lortet,  Dr. 

Lyman,   Dr.   David  R. 

Mailbags,  Infection  through 
Marriage  of  the  Tuberculous 
Maryland  State  Sanatorium 
Massachusetts  State  Sanatorium 
McFaul,  Rt.  Rev.  James  A. 
Meat,  Tuberculous 
Medical  Guidance,  Necessity  of 
Medical  Supervision  of  Patients 
Metchnikoff,  Professor  E.  . 
Metropolitan  Life  Insurance  Company 
Michigan  State  Sanatorium 
Milk  and  Tuberculosis 
Miller,  Dr.  James  Alexander 
Millet,  Dr.  C.  S. 
Miner's  Tuberculosis 
Minnesota  State  Sanatorium 
Misery,  Social,  and  Tuberculosis 
Missouri  State  Sanatorium 
Mothers'  Education  in  Tuberculosis 
Mothers,  Tuberculous 
Mouth  Breathing 
Mouthmask,  Frankel's 
Municipal  Authorities,  Duties  of 
Muskoka  Cottage  Sanatorium     . 

National  Association  . 

National  Jewish  Hospital 

National  Pythian  Sanatorium 

Natural  Defense,  Means  of 

New  Hampshire  State  Sanatorium 

New  Jersey  State  Sanatorium     . 

New  Mexico  Cottage  Sanatorium 

Newsholme,  Dr. 

New  York  City  Open  Air  School 

New  York  C.  O.  S.  Tuberculosis  Work 


PAGE 

326,  328,  330,  332 
295 
325 


220, 


174, 


350, 


37i> 

6: 

364, 
281, 


289, 


293. 


224 

354 
181 
176 
288 
216 

15 
173 

18 

378 
182 
166 
274 
',  74 
233 
184 
382 
186 

354 
18 

356 
205 
126 
337 

372 
294 
373 
17 
196 

187 
333 
350 
272 

305 


390 


INDEX 


New  York  Milk  Committee 

New  York  State  Sanatorium 

New  York  Tuberculosis  Clinics 

Night  Air,  Fear  of      . 

Night  Camps      .... 

Non-Alcoholic  Drinks 

Nordrach  Ranch  Sanatorium 

North  Carolina  State  Sanatorium 

Notification          .... 

Number  of  Institutions  in  the  United  States 

Number  of  Associations  in  the  United  States 

Nurses        .  ...... 

Occupations  Suited  for  the  Tuberculous    . 

Occupations  Unsuited  for  the  Tuberculous 

Oderberg  Sanatorium  for  Tuberculous  Policy 

Offices,  Tuberculosis  in 

Ohio  State  Sanatorium 

Open  Air  Schools 

Open  Air  School  "Southfield" 

Open  Air  Model  Tenements 

Open  Air  Private  Dwellings 

Osier,  Professor  William     , 

Otis,  Professor  Edw.  O. 

Outdoor  Sleeping 

Outdoor  Sleeping,  Dress  for 

Overwork  in  Prisons 

Overwork  in  Schools    . 


Parsons,  Mrs.  Henry 

Pasteur,  Louis 293,  295,  379 

Pasteurization 19 

Patients  at  Work 

Patients'  Duty     . 

Pennsylvania  State  South  Mountain  Sanatorium 

People,  Duties  of  the 

Perkins,  Dr.  J.    . 

Philadelphia  Protst.  Epi.sc.  City  Mission  House  for  Consumptives 

Philanthropists,  Duties  of 


138 


149 


42,  156, 
Holders 


270. 


24,   2 
59,  98 


5, 


324 

201 
42 


271 

97 

108 

27 
103 


PAGE 

307 
188 

119 
338 
364 

334 
189 

43 
317 
372 
329 

226 
169 

377 
229 

190 

272 

272 

99 

109 

372 
24 

344 
76 

209 

251 


262 
380 
167 
332 
4 
191 

351 
270 
290 
284 


INDEX 


391 


at  Seabreeze 


PAGE 

Phipps,  Mr.  Henry 3^2 

Phipps  Institute  for  the  Study  and  Prevention  of  Tuberculosis  312 

Phthisiophobia    .... 

Physicians'  Duties 

Physicians,  General  Advice  from 

Physicians,  Special  Advice  from 

Physiological  Poverty 

Plan  for  Disinfecting  Mailbags    . 

Plan,  Prize,  for  Tenements 

Playground  for  Tuberculous  Children 

Playgrounds         .... 

Playgrounds  for  Public  Schools  . 

Pocket  Flasks      .... 

Police  Power  of  Health  Department 

Postmaster-General     . 

Post-natal  Infection    . 

Post  Offices,  Tuberculosis  in 

Pratt,  Dr.  Joseph  H.    . 

Precautions,  Anti-tuberculosis     . 

Predisposition,  Overcoming  of     . 

Pregnant  Woman,  Care  of  . 

Prevention  by  Insurance  of  the  Peopl 

Preventorium     .... 

Printers'  Union  Home  for  Consumptives 

Prisons,  Tuberculosis  in 

Probst,  Dr.  Charles  O. 

Proctor,  Senator  Redfield    . 

Proedohl's  Spittoon     . 

Prohibition  .... 

Protestant  Episcopal  Home  for  Consumptives 

Providence  Open  Air  School 

Prudden,   Professor  T.   IMitchell 

Public  Press,  Duties  of  the 

Purdy,  Dr.  Charles  W. 

Pythian  Sanatorium    . 

Railroads  and  Tuberculosis 
Ransom,  Dr.  J.  B.      . 


S>  21 


e  Against  Tuberculosis 


i97> 


168, 


22 

274 

28 

43 

47 

54 

18 

224 

95 

278 

91 

164 

246 

247 

8 

160 

218 

20 

41 

218 

220 

299 

349 

203 

323 

354 

354 

5 

378 

157 

342 

374 

199 

210 

190 

190 

202 

,  215 

362 

290 

270 

123 

246 

280 

296 

373 

235 

24 

207 

392 


INDEX 


Death  Rate  in  Glasgow 


Reaction     . 

Recitations 

R^d  Cross  Camp 

Red  Cross  Society 

Red  Cross  Stamp 

Reduction  in  Tuberculosis 

Registration 

Research     . 

Respirator)'  Exercises 

Rest-cure    . 

Richer,  Dr.  Arthur  J. 

Riverside  Hospital  Sanatorium 

Rhode  Island  State  Sanatorium 

Rockefeller  Institute,  New  York. 

Rockefeller,  Mr.  John  D     . 

Rogers,  Dr.  Oscar  H. 

Roof  Camping     . 

Roof  Gardens 

Room,  Consumptive's 

Rosenau,  Dr.  J.  N.     . 

Rothrock,  Dr.  A.  N.    . 

Royal  Hospital  for  Consumptives  at  Ventnor 

Royal  League  Sanatorium    . 

Sachs,  Dr.  Theodore  B.     . 

Sage,  Russell,  Foundation 

Sailors,  Tuberculous 

Sanatoria      .         .         •  3i>   156,   158,   160,   172 

Sanatoria  as  Educators 

Sanatorium,  Its  Medical  Mission 

Sanatorium,  Its  Social  Mission 

Sanitary  Private  House  for  Laborers 

Sanitary  Tenements  for  Tuberculous  Families 

School  Age  of  Pupil  Entering 

School  Farms 

School  Hygiene. 

SchcK)l  Lunches    . 

Schools  and  Tuberculosis   . 


289 


si6 


PAGE 

357 

260 

338 

370 

370 

370 

350 

43 

312 

253 

59 

79 

342 

162 

192 

312 

158 

146 

105 

91 

347 

56 

167 

191 

345 

376 

324 

3ii> 

321 

217, 

244 

33^, 

378 

33^ 

323 

329 

112 

346 

251 

262 

248 

263 

41, 

246 

INDEX 


393 


PAGE 


vanced  Cases, 


Schottelius,  Dr.    . 

Schrader,  Mr.  Geo.  H.  F.    . 

Sea  Breeze  Sanatorium 

Seaside  Sanatorium     . 

Segregation,  Institutional,  for  Ad 

Sermons,  Anti-tuberculous 

Servants,  Tuberculous 

Seton  Hospital 

Sharon  Sanatorium 

Shively,  Dr.  Henry  L. 

Shively  Sanitary  Tenement 

Shack,  Millet's    . 

Short,  Mr.  R.  Thomas       . 

Singing        .... 

Sleeping  Porch  or  Balcony. 

Smith,  Mr.  Henry  Atterbury, 

Smoke  Nuisance 

Soldiers,  Tuberculous 

Spittoons     .... 

Star  Ranch,  Colorado  Springs 

State  Authorities,  Duties  of 

State  Sanatorium,  Location  of 

Statistics    .... 

Sterilization 

Sternberg,  Surgeon-General  Geo 

Stimulants 

St.  Joseph's  Hospital 

Street  Sprinkling 

Sunday  Tuberculosis  in  Churches 

Surgeon-General  Marine  Hospital  Service 

Sweatshops  .... 

Sweeping    ..... 

Swimming  Lessons  in  School 

Swine,  Tuberculosis  in 

Symptoms,  Early,  of  Tuberculosis 

Taft,  Hon.  Wm.  H.     .         .         . 
Teachers'  Duties 


-/  / 


M, 


211 


158, 


7, 


297> 


.  295 

.  281 

),  276 

,  278,  315 

.  276,  278 

•  350 

.  289 

•  233 

.  289,  292 

•  335 

•  344,  346 

•  346,  348 

.  62,  63 

•  94 

.  260 

60,  62 

.  346 

.  128 

.  217 

8,  16 

132,  201 

•  336 

.  171 

.  172 

,  327 

353,  372 

•  19 

•  372 

•  52 

289,  291 

•  131 

•  245 

.  227 

.  214 

21,  123 

.  248 

.  242 

268,  352 

.  227 

.  246 

394 


INDEX 


PAGE 


Telephones,  Protection  from  Possible  Infection 

Tenement  Houses 

Tents 

Topography  for  State  Sanatorium 

Treating  Habit    . 

Treatment  at  Home 

Trudeau,  Dr.  Edw.  L 

TubercuHn  Tests 

Tuberculosis,  Pulmonary,  Definition  of 

Tuberculous  Teachers 

Tucker 

Tyson,  Professor  James 

Underwear,  Sanitary 

Union  Printers'  Home  for  Consumptives 

Vanderbilt,  Mrs.  "Wm.  K.,  Sen. 

Van  Pelt,  Professor  John  V. 

Veiller,  Mr.   Lawrence 

Ventilation,  Proper      .         .         .         .         .in 

Vermont  State  Sanatorium 

Vivisection,  Scientific 

Wald,  Miss  Lillian  D. 
Watchfulness  for  Early  Symptoms 
Waters,  Dr.  Bertram  H. 
Wehrawald  Sanatorium,   Germany 
Weicker's  Sanatorium  at  Goerbersdorf 
Welch,   Professor  Wm.  H. 
West  Virginia  State  Sanatorium 
Whitewash  Scales 
White,  Dr.  Wm.  Charles     . 
Willard,  Mrs.  Henry    , 
Windows,  French 
Window-tent,  Knopf's 
Wisconsin  State  Sanatorium 
Woman  Labor    . 
Worcester,  Rev.  Dr.  Elwood 
Workshops  in   Prisons 
W^nne   State   Farm,   Texas 


24,   2 


5,  27 


229 


98 
238 


lOI 


234 

95,  98,  215 

66 

. 

172 

3(>3 

•  57> 

301 

>  333} 

372 

241 

3 

278 

66 

24 

12 

374 

■   344, 

346 

,  107, 

112 

306 

,  347, 

355 

195 

312 

282 

352 

283 

341 

•  343, 

375 

•  350, 

351 

196 

206 

338 

311 

107, 

248 

67 

194 

212 

299 

210 

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